Level 1: Internal Routine Site QA/QC Checks
The base of the monitoring pyramid relies on direct site-level QA/QC of all field and laboratory activities. Although management structures vary by site, the basic field hierarchy involves site managers overseeing field supervisors, who then oversee the CHW supervisors, who in turn oversee the CHWs.
Among CHWs, supervision and auditing with feedback are effective in achieving and maintaining high-quality performance, and having several parallel support and monitoring techniques improves and maintains performance levels.14 Therefore, ANISA project sites employ various mutually supportive methods to ensure optimal continued performance of CHWs. These methods include routine data collection form rechecking and random observations of visits by supervisors, who subsequently provide feedback or re-training to CHWs to improve and maintain performance. CHW home visits are observed by supervisors, who also conduct random independent visits at a subset of households to re-check the CHW’s assessment accuracy and data collection form entry. The coordination team provides guidelines, including minimum frequencies of random and systematic checks, although sites are free to increase their oversight in this regard (Table 1). Additionally, refresher training is provided via both regular and targeted retraining to maintain quality of young infant assessment and record-keeping skills over time. Common inconsistencies found in the on-site data centers are relayed to field management, so that they can identify the source of these errors and correct problems in filling out the data collection forms. Together, these internal site QA/QC techniques allow for rapid detection and correction of issues and serve to safeguard the quality of study data.
All sites face different contextual challenges, including different levels of in-migration and out-migration, internal movement of pregnant women, traffic conditions, weather, law-and-order situations as well as unique geographical features. Study staff address these challenges by employing locally appropriate strategies. Strong internal site QA, setting realistic site-specific targets for activities and ongoing community engagement create a system of accountability and project ownership at the site level, forming the strong base of the monitoring and evaluation pyramid.
Level 2: Performance Monitoring via Monthly Field and Laboratory Report Forms
The primary goal of the study is the collection and analysis of a representative sample of quality biological specimens from both sick young infants showing signs of pSBI and healthy control infants, in the first 59 days of life in community settings. Achieving this goal involves coordination of research activities in the field and laboratories via continuous monitoring of a number of performance indicators. These indicators are connected through a chain of dependent activities at each site, starting from recruitment of participants and scheduled visitation, toward the successful collection and processing of specimens. Each stage of the workflow may potentially act as a bottleneck and limit the overall field success and thus the representativeness of the study, threatening the validity of findings. The coordination team monitors activities using quantitative report forms submitted by the sites on a monthly basis. These forms contain 64 numerical elements of the field (40) and laboratory (24) components with specific significance to project performance (Table 2). Laboratory forms capture key numbers, samples tested, bacterial isolates from blood culture and molecular test results.
Monthly report evaluation is performed across all sites using simple, transparent formulae allowing for the pooling and cross-comparison of overall project performance data. When evaluating these forms, readily interpretable estimates are used to show performance, initiate dialogue, and encourage site teams to continue real progress or undertake appropriate corrective actions where indicated. The economy of elements in field and laboratory activities and straightforward evaluation and feedback are preferable in our multisite study to more complex calculations, which could lead to disagreements about the calculations, rather than a discussion of underlying performance.
The monthly monitoring reports are collected from all sites within 10 days of the end of the preceding month. The figures from these reports are recorded in Microsoft Excel, which is used to produce routine performance charts each month. This method provides a comparison of the same metrics against both the study targets and performance of the site in previous months. Charts and figures are reviewed and shared; monthly declines in performance of over 10% in any of the critical areas or other interesting trends are routinely discussed with each respective site during conference calls.
Level 3: Database-based Monitoring
All completed field data collection forms and laboratory results are uploaded to a central database and are available for analysis by the coordination team to support monitoring and evaluation activities. Querying incoming data allows for more in-depth monitoring of field, clinical and laboratory performance than is possible via the monthly reports. The database query also helps determine if a site’s data upload quantity and quality are being maintained and are consistent with expectations.
Database frequency tables of entered forms are routinely cross-compared with the expected number of forms collected and studied alongside the monthly reports. This cross-comparison is key to evaluating a site’s data entry performance and to avoid any large form entry backlog.
The quality of the incoming data is scrutinized using (i) the proportion of data collection forms that undergo the required double entry and (ii) automated internal consistency and logical checking algorithms. Feedback tables are regularly shared with data personnel and site teams to ensure early resolution of problems. We utilize historical data on field activities, detected clinical signs and real-time data found in the text message system, which synchronizes with the data server daily to detect births, case diagnoses and control enrollment. Together these data sets are scrutinized, and feedback is provided to sites. With the help of the site teams, appropriate inquiries and solutions are devised by cross-comparing monthly monitoring forms, the database and the text message data. Table 3 illustrates how we used the database to identify and solve problems related to healthy control selection.
Project laboratory data are entered into the site database directly by the laboratory staff. These data are securely transmitted to the coordination center and subsequently to CDC for in-depth analysis, evaluation, detailed feedback and suggestions for resolution of problems found in processing and analysis of specimens. The project database allows the coordination team to confirm and detail issues detected by the monthly monitoring reports, streamline data capture, ensure data quality and inform CDC of all relevant laboratory details for evaluation and feedback.
Level 4: Site Visits
Although local, monthly and data monitoring and evaluation activities provide the coordination team with copious monitoring data, there is no alternative for meeting with and observing project personnel in action. Thus, periodic visits are made to the study sites by internal and external monitors to observe implementation of the protocol, the daily activities of staff operating in the community, health care facilities, data centers and study laboratories. Internal monitors are selected from the ANISA coordination team and project administrators, whereas external monitors are subject matter experts from the World Health Organization, the Hospital for Sick Children in Toronto, CDC and other affiliated organizations with expertise in critical appraisal of similar projects in complex field and laboratory environments.
These visits are informed by monthly database monitoring activities and provide further information on site functionality, workflow, staff skills and other practical issues.
The monitors write comprehensive visit reports, which are reviewed and shared with the coordination team and the site leaders for discussion and prompt resolution of detected issues. External monitors also provide expert advice and ideas that are beneficial to project implementation at the site. A standard list of project elements is checked during these visits (Table 4), including logistical aspects. Site visits are scheduled once or twice a year and are indispensable for detecting and resolving issues.
Both internal and external monitors are briefed in detail before these visits and provided with site-specific recommendations generated by previous visits and current database and monthly monitoring reports. Site visits present a unique opportunity to build rapport, provide feedback to sites and solve in person any pending issues flagged by other monitoring activities. Feedback from these visits and recommendations for improvement of protocol application are shared with the sites and stakeholders, so appropriate remedial actions can be agreed together with the site leaders.
APPLICATION AND UTILITY OF THE MONITORING STRUCTURE—THE ANISA EXPERIENCE
The pilot phase of the study was implemented at each ANISA site. All study physicians, support and laboratory staff and data entry personnel used this time period to become familiar with the protocol and to gain proficiency working together in implementing it, identifying issues, and providing feedback to the coordination team. Critically, the monitoring system was in place, and monitoring data were collected from the beginning of the pilot phase. The pilot phase also allowed for refinement and improvement of the elements within the monitoring tools and analysis techniques used.
The pilot phase involved monitoring key performance elements such as the timing of the first assessment of the newborn after delivery, the proportion of successful referrals, levels of consent to specimen collection, timing of specimens reaching the laboratory and blood contamination rates. For the sites in Bangladesh and Pakistan, basic thresholds were agreed upon by the respective site PIs and the coordination team to indicate whether the site was operating satisfactorily (Table 5). Based on evaluation of this site performance data, the site leaders and the coordination team agreed upon the end date of the pilot phase and commencement of the main study at that site in a retrospective manner (see Fig. 3 for more details)
For the sites in Bangladesh and Pakistan, the earliest sites to commence, the pilot phase was retroactively defined (as explained above), but the Indian sites undertook a predefined pilot period of 1 month as they started much later and had the benefit of joining the study after extensive streamlining of procedures. Conducting a pilot phase at an ANISA site until the desired performance levels were reached and maintaining that performance afterwards required commitment of the site leaders and regular feedback from the coordination team and stakeholders.
SUMMARY AND CONCLUSION
Together, ANISA’s 4 overlapping monitoring layers and straightforward evaluation and communications allow the study investigators to detect issues and track numerous developments in the field, clinical and laboratory components of the project to make informed decisions.
A comprehensive system of harmonized site monitoring elements increases the odds that each site will adhere strictly to all elements in the study protocol evenly. It allows for both the coordination team and the donor to be confident in the site investigators’ understanding and control of issues within the bounds of the study. The ability to examine the key activities across project sites in a simple, inclusive and transparent way also allows for a shift from an implementation focus to a management focus. Finally, it enables a shift to a results-based monitoring focus once the sites are functioning satisfactorily, and the project is on a path towards fulfilling its objectives.
Continuous monitoring of project activities leads to the adoption of various new strategies, staffing and oversight which strengthen both the active and passive surveillance structures at study sites. These strategies have already improved coverage and maximized engagement of sites with their at-risk communities.
A blood contamination workshop in February 2012 (Fig. 4) was the direct result of regular monitoring of contamination rates at the study sites from the pilot phase. If the results of laboratory investigations had not been monitored and scrutinized so regularly and closely, it would not have been possible to justify devising new strategies and developing more intensive guidelines for limiting contamination of neonatal blood specimens; it certainly would not have allowed these measures to be implemented mid-stream to improve study outcomes.
In conclusion, the straightforward monitoring structure of ANISA is indispensable to identifying, sharing and resolving underlying issues with the help of partners and continues to facilitate the success of the project and safeguarding of the validity of the study findings.
The authors gratefully acknowledge the technical assistance of Mr. Mahmudur Rahman and Ms. Mahfuza Marzan, as well as our numerous talented and supportive colleagues at CHRF, icddr,b and CDC.
The ANISA Methods Group: A. S. M. Nawshad Uddin Ahmed and Belal Hossain (Child Health Research Foundation, Dhaka, Bangladesh); Qazi Sadeq-ur Rahman and Tanvir Hossain (Centre for Child and Adolescent Health, International Centrefor Diarrhoeal Disease Research, Dhaka, Bangladesh); Jonas M.Winchell, Maureen H. Diaz, Nong Shang, Yoonjoung Choi, and Stephanie J. Schrag, DPhil (Centers for Disease Control and Prevention, Atlanta, GA); Aarti Kumar and Vishwajeet Kumar (Community Empowerment Lab, Lucknow, India); Arif Billah, LukeMullany, Mathuram Santosham and Nazma Begum (Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD); Daniel E. Roth (Department of Paediatrics, Hospital for Sick Children and University of Toronto, Canada); Derrick Crook (John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom); Stephen P. Luby (Stanford Woods Institute for the Environment, Stanford University, Stanford, CA) and Abdul Momin Kazi, Imran Ahmed, Shahida M. Qureshi, Sheraz Ahmed and Zulfiqar A. Bhutta (The Aga Khan University, Karachi, Pakistan).
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
monitoring and evaluation; multi-site; ANISA; neonatal; surveillance; project design