The Systems Analysis and Improvement Approach: Data-driven Quality Improvement
Authors: Gimbel Sarah , Ásbjörnsdóttir Kristjana , Banek Kristin , Borges Madeline , Crocker Jonny , Coutinho Joana , Cumbe Vasco , Dinis Aneth , Eastment McKenna , Gaitho Douglas , Lambdin Barrot , Pope Stephen , Uetela Onei , Hazim Carmen , McClelland R. Scott , Mocumbi Ana Olga , Muanido Alberto , Nduati Ruth , Njuguna Irene , Wagenaar Bradley , Wagner Anjuli , Wanje George , Sherr Kenneth 
Published: August 2022

Abstract
Background: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline healthcare workers (HCW) are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages HCW in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings, but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the United States. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches, and thus improve reproducibility, guide future adaptations and lay the groundwork to define its mechanism of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies; facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.