Conducting a Surveillance Data Quality Audit in Grand Bassa County, Liberia, November 2015 African Case Studies in Public Health

Public health officials depend on timely, complete, and accurate surveillance data for decision making. The quality of data generated from surveillance is highly dependent on external and internal factors which may either impede or enhance surveillance activities. One way of identifying challenges affecting the quality of data generated is to conduct a data quality audit. This case study, based on an audit conducted by residents of the Liberia Frontline Field Epidemiology Training Program, was designed to be a classroom simulation of a data quality audit in a health facility. It is suited to enforce theoretical lectures in surveillance data quality and auditing. The target group is public health trainees, who should be able to complete this exercise in approximately 2 hours and 30 minutes. How to Use the Case Study General instructions: A class of up to 20 trainees is ideal for a training sessions using this case study. The instructor facilitating the session should direct a participant to read a paragraph out loud, going around the room to give each participant a chance to read. Based on the type of question, the instructor may decide to divide the class into small groups for exercises, randomly identify a trainee to respond to the question, or engage the class in a group discussion of the answer. The aim of the interaction is to allow participants to learn from each other and not just from the instructor. Specific instructor’s notes are included with each question in the instructor’s version of this case study. Audience: Residents in Frontline Field Epidemiology Training Programs (FETP-Frontline), Field Epidemiology and Laboratory Training Programs (FELTPs), and others who are interested in this topic. Prerequisites: For this case study, trainees should have received lectures on data quality, data quality auditing, and SWOT analysis. Materials needed: Flipchart or white board with markers Level of training and associated public health activity: Novice – Data Quality Auditing Time required: Approximately 2-3 hours


Introduction
In 2014, Liberia experienced an outbreak of Ebola virus disease (EVD) which claimed the lives of many locals [1]. The Ministry of Health (MoH) realised, in attempting to rapidly assess and effectively manage the outbreak, that there were major gaps in their surveillance and response system. In reaction, the Ministry of Health developed an Investment Plan for Building a Resilient Health System (2015)(2016)(2017)(2018)(2019)(2020)(2021) to outline the strategy for developing a health system "that is able to anticipate, detect early, respond to and quickly recover from health emergencies" [2]. To help the MoH achieve its objectives, 92 district surveillance officers (DSOs) were recruited and trained to serve as supervisors at the district and community level. As part of their training, they were enrolled in a Frontline Field Epidemiology Training Program (FETP-Frontline) to equip them with the necessary skills for their work.
The newly trained DSO for District A appreciated the importance of collecting quality data to support effective surveillance. She recognised that although surveillance had been ongoing in her district over the years, the quality of data was a pressing concern. She therefore made it her mandate to improve the quality of data from her district by applying new skills learned in FETP-Frontline training [3]. To achieve this, the DSO conducted a data quality audit in District A to identify existing gaps in surveillance activities and take action based on findings [3]. Question 1. What is data quality in surveillance?

Part 1
Following approval by the County Health Officer and District Health Officer, the data quality audit was carried out by the District A DSO from 19-21 November 2015 in the three health facilities (Clinics A, B and C) which provided healthcare to the district. The DSO conducted interviews with key staff in the facilities and completed a data quality audit worksheet (see Appendix 1) based on direct observations. The worksheet included questions regarding data collection, reporting, analysis, interpretation, public health action, and evaluation conducted by the health facility [3].
Question 5. In relation to surveillance, whom will you consider as key staff in your health facilities and why?
Question 6. Review the data quality worksheet below. Indicate how you will verify information provided by facility staff under each activity during the audit. Question 7. Form three groups with each group representing a facility. Select one member from each group who will role play as the DSO for District A. The remaining group members will serve as key staff in the facilities. The person playing the role of the DSO will complete the DQA worksheet (see Appendix 1) based on information provided by those playing the role of key staff (see Appendix 2).

Part 2
After successful completion of the audit at each health facility, the DSO used the opportunity to sensitise the health workers on diseases of high priority, as well as the importance of careful and regular case reporting. On return from her visit, she decided to perform a SWOT analysis of her findings [3].
Question 8. What is a SWOT analysis?
Question 9. What is the difference between strengths and opportunities in a SWOT analysis?
Question 10. What is the difference between weaknesses and threats in a SWOT analysis? The DSO prepared her recommendation based on SWOT findings. A summary report was developed and shared with all stakeholders for prompt action to be taken. The DSO decided to focus on actions that were within her control and to follow up on other stakeholders to ensure that other outstanding recommendations were implemented [3].
Question 12. If you were the DSO, what recommendations would you give regarding this delegation process? Outline the problems/challenges, recommendations, and person responsible. A month after the District A DSO conducted the data quality audit, her supervisor, the County Surveillance Officer (CSO), conducted an assessment to measure any improvement in surveillance activities at the facilities. From his assessment, he observed that facilities started drawing crude spot maps for priority diseases in their catchment area based on training they received from the DSO. The health facilities also monitored the trend of priority diseases using a line graph. The CSO also observed that Officer in Charge of the facility was now routinely verifying surveillance data captured at the facility [3].
Question 15. Prepare a summary report for the data quality audit as per this case study

Conclusion
The data quality audit helped the District A DSO to identify key factors influencing surveillance data quality in the district. In action taken after the quality audit, there was remarkable improvement in the accuracy and completeness of the data produced.
A strong surveillance system needs to have an effective way of systematically collecting, analysing, and interpreting quality surveillance data to inform public health action. To ensure early detection and response to diseases of concern as well as to maintain a healthy population, a strong surveillance at the lowest level is the first point of call. However, health care workers are often faced with major constraints which hinders their ability to carry out their duties effectively, thereby affecting the timeliness and quality of data reported. Monitoring and evaluation of surveillance activities at the facility and community level will help to sustain the efforts made in improving data quality as well as build a strong partnership among districts and communities for early disease detection and effective response. When was the last time a supervisor made a site visit to your facility? 3

Background Reading
How often do you report information to the next level? 4 Is there a standard method for reporting each reportable disease? 5 Is there a standard method for reporting each immediately reportable disease? 6 Is there a standard method of reporting an outbreak? 7 Is the report case-based or aggregate format? 8 Is the reporting protocol process mapped out or summarised in narrative format and readily visible in the facility (e.g. on the wall)? 9 For notifiable diseases, are "0" cases recorded and reported? 10 For immediately reportable diseases such as Ebola, are "0" cases recorded and reported? 11 Are each of the IRD consistently reported in a timely manner? How frequently do you review and collect data (e.g. daily, weekly, monthly)?
Data is collected daily, but review is not done at facility level 3 Is there a list of the country's notifiable diseases?
There is a list of the country's notifiable diseases but not on wall due to renovation 4 Is there a list of immediately reportable diseases (IRD)?
There is a list of immediately reportable diseases but not on wall due to renovation 5 For each IRD, does this facility have case definitions for suspect and confirmed cases? How often do you report information to the next level?
Daily, weekly, and monthly 4 Is there a standard method for reporting each reportable disease?
Yes, but not displayed on wall 5 Is there a standard method for reporting each immediately reportable disease?
Yes, but not displayed on wall 6 Is there a standard method of reporting an outbreak?
Yes, but not displayed on wall.
Response initiated at local level 7 Is the report case-based or aggregate format? Initial report is by alert notification using a case-based form. A line list is then prepared for all identified cases 8 Is the reporting protocol process mapped out or summarised in narrative format and readily visible in the facility (e.g. on the wall)?
Reporting protocol is mapped out but not readily visible on wall 9 For notifiable diseases, are "0" cases recorded and reported?
Zero cases are reported and recorded in the IDSR ledger 10 For immediately reportable diseases such as Ebola, are "0" cases recorded and reported?
Zero cases are reported and recorded in the IDSR ledger