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Cote d'Ivoire
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Comparative Study to Assess the Impact of Collaborative Improvement on Customer Satisfaction, Provider Satisfaction, and Services for PLWHA | Cote d'Ivoire
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The National Program for Medical Management of People Living with HIV (PNPEC), the Ministry of Health and Public Hygiene, the USAID Health Care Improvement Project (HCI), and several other partners have been implementing a collaborative approach to improve the quality of HIV services in Cote d'Ivoire since 2009. This collaborative approach was conducted in two phases: a demonstration from January 2009 to March 2010 in 41 sites and an expansion phase which added and additional 80 sites and began in May 2010. Before the introduction of HCI project, a baseline assessment was conducted in pilot sites in 2008, which revealed significant opportunities to improve different components of HIV care, including in the areas of customer and provider satisfaction.
The overall objective of this cross-sectional study is to measure the effect of the HCI-supported collaborative to improve the quality of services for PLWHA on client satisfaction, provider satisfaction, and HIV services. The study will include an exposed group and an unexposed group. Pilot sites that participated in the collaborative improvement effort will be included in the exposed group and sites that received no quality program will be counted among the non-exposed group. -
Rapport d’Activités de la Phase de Démonstration du Collaboratif d’Amélioration de la Qualité des Services et Soins VIH en Côte d’Ivoire
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Ce rapport décrit les résultats de la phase de démonstration d’une collaborative d'amélioration en Cote d'Ivoire mis en œuvre par le Projet de l’Amélioration des Soins de Santé de l’USAID (HCI), le Programme National de Prise en Charge Médicale des Personnes Vivant avec le VIH (PNPEC), et le Ministère de la Santé et de l’Hygiène Publique pour améliorer la qualité des services VIH.
Une évaluation initiale de la qualité de la prise en charge des Personne Vivant avec le VIH (PVVIH) réalisée en Juillet-Août 2008 dans 33 structures sanitaires réparties sur tout le territoire national, a montré d’importantes opportunités d’amélioration aux différentes composantes de la prise en charge. Après la restitution des résultats de l’évaluation initiale et la mise en places des organes du collaboratif, 41 sites (dont 34 sites de la Prévention de la Transmission Mère Enfant, ou PTME, et 38 sites de la prise en charge des antirétroviral, ou ARV) ont été sélectionnés pour la phase de démonstration du collaboratif. -
Results from the Pilot Phase of an ART/PMTCT Improvement Collaborative in Cote d’Ivoire
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This technical report describes results achieved during the demonstration phase of an improvement collaborative implemented in Cote d’Ivoire by the USAID Health Care Improvement Project (HCI), the National Program for the Medical Management of People Living with HIV/AIDS (PNPEC), and the Ministry of Health and Public Hygiene in order to improve the quality of HIV services.
An initial evaluation of the quality of care and treatment for persons living with HIV (PLHIV) was conducted from July – August 2008 in 33 health care centers throughout Cote d’Ivoire in order to draw attention to the need for improvements among different components of care and treatment services. After the restitution of the results of the initial evaluation and the establishment of the elements of an improvement collaborative, 41 sites were selected to participate in the demonstration phase of the collaborative. Of these 41 sites, 34 provide prevention of mother to child transmission of HIV (PMTCT) services, and 38 provide anti-retroviral (ARV) treatment services.
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Cote d’Ivoire| HIV Care and Treatment-ART and PMTCT Spread Collaborative
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Collaborative Profile
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Effets du collaboratif d’amélioration sur les indicateurs PTME et ARV en Côte d’Ivoire : Etude Comparative
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La Côte d’Ivoire a une prévalence élevée du VIH, avec 4,7 % de la population infectée par le virus. Cependant en 2008, une évaluation nationale de la prévention de la transmission mère-enfant du VIH (PTME) et les services de thérapie antirétrovirale (ARV) ont montré un écart important dans la qualité des soins tant dans le secteur privé que public. Pour mesurer les effets du collaboratif quant à la réduction des écarts, le Projet d’Amélioration des soins de santé de l’USAID (HCI) en Côte d’Ivoire, a comparé les résultats obtenus dans les sites de démonstration et ceux obtenus sur de nouveaux sites qui allaient rejoindre le projet. Ce rapport décrit le collaboratif d’amélioration qui a été mis en place par HCI en 2009 pour améliorer les soins et services ARV/PTME offerts aux PVVIH (Personne Vivant avec le VIH).
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Amélioration des soins communautaires pour les orphelins et enfants vulnérables à Travers un Processus d’Amélioration de la Qualité
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Pour répondre à la problématique des Orphelins et Enfants Vulnérables (OEV) en Côte d’Ivoire, le Projet d’Amélioration des soins de santé (HCI) de l’USAID, le Ministère de la Femme, de la Famille et des Affaires Sociales (MFFAS), et le Programme National de prise en charge des OEV (PN-OEV) ont engagés le processus d’Amélioration de la Qualité des services pour découvrir les insuffisances des soins et soutiens offerts aux OEV et à leurs familles. Ce rapport décrit les interventions mis en œuvre par HCI et leurs partenaires pour améliorer la qualité des services offerts aux OEV qui a démarré en 2009.
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Améliorer la documentation et le maintien des patients dans le programme de prise en charge du VIH en Côte d’Ivoire
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En 2008, à la demande du Ministère de la santé, avec l’appui financier du PEPFAR, le Projet d’Amélioration des Soins de Santé de l’USAID (HCI) a été invité à assister le Programme National de Prise en Charge des personnes vivant avec le VIH (PNPEC) pour conduire une évaluation nationale de la qualité des soins dans le domaine du VIH en Côte d’Ivoire. HCI et les partenaires de mise en œuvre ont conduit une évaluation nationale de la qualité des soins et services offerts aux PVVIH. Sur la base de l’évaluation, un comité technique dirigé par le PNPEC avec l’appui technique d’URC a développé un paquet de changement pour améliorer la documentation, le suivi et la rétention des patients. Ce rapport décrit les résultats du collaboratif d’amélioration d’ARV/PTME.
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Amélioration de la Qualité des Soins et Services en Côte d'Ivoire
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Apres plus d’une décennie de soin et de traitement d’ARV, il semble très important pour le PNPEC de se concentrer sur la qualité des interventions. Pour répondre à ce besoin, le PNPEC à fait appel au support technique d’URC pour mettre en œuvre un processus d’amélioration de la qualité avec le soutien financier du PEPFAR. Les résultats de cet effort national à travers le Projet d’Amélioration des Soins de Santé de l'USAID (HCI) conduit par URC.Ce rapport décrit les objectifs de quatre projets d’amélioration dirigés par HCI en Cote d’Ivoire :1. ARV-PTME : Améliorer la qualité de la prise en charge des PVVIH par le traitement antirétroviral et celle des services de prévention de la transmission mère-enfant du VIH.2. OEV : Améliorer la qualité des services offerts aux OEV et leurs familles à travers le développement des normes et bonnes pratiques.3. Prévention : Développer la norme Nationale pour les programmes d’éducation par les pairs dans le domaine du VIH/sida.4. Laboratoire : Renforcer les capacités techniques des laboratoires impliqués dans le programme d’accréditation selon le schéma OMS-AFRO.
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Cote d'Ivoire | ART and PMTCT Demonstration Collaborative
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Collaborative Profile
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Shared Learning in Collaborative Improvement: Spread of Changes to Improve PMTCT and ART Services among QI Teams in Cote d'Ivoire
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A 2008 assessment of the quality of care and treatment for people living with HIV/AIDS (PLWHA) in Cote d’Ivoire revealed that there was a significant need for improvement in terms of adherence to standard of care and patient retention. As a result, Cote d’Ivoire’s Ministry of Health and its National Program for HIV Care and Treatment (PNPEC) and the USAID Health Care Improvement Project (HCI) launched an HIV collaborative improvement initiative in December 2008 in partnership with PEPFAR and implementing partners. This collaborative provided an opportunity to study the process of shared learning that occurs among quality improvement teams.The main objective of this study is to better understand the methods and level of spread of ideas tested by a quality improvement team from one site to another, and the factors facilitating or limiting the spread of these ideas. This study therefore aims to assess sharing mechanisms available to teams during the demonstration phase of the collaborative and the factors that facilitate the sharing process.The specific objectives of this study are to: 1) Describe the methods for sharing across quality improvement teams; 2) Examine the factors that facilitate sharing; 3) Obtain an inventory of the changes tested by the teams and identify the source of those ideas; 4) Examine factors facilitating or hindering the decision to apply changes; and 5) Identify strategies to improve the spread of ideas between quality improvement teams.MethodsThis cross-sectional study was conducted in January and February 2010 in the PMTC and ART sites that participated in the demonstration phase of the collaborative. The study included thirty four (34) health facilities out of a total of forty-one (41) sites of the collaborative demonstration phase: 5 regional hospitals, 12 general hospitals and 17 other health facilities. Data were collected by URC Cote d’Ivoire staff and three staff members from the Ministry of Health. Data collection tools included questions about sharing mechanisms used in the last quarter, factors facilitating or restricting their use, changes implemented in the sites and sources of ideas for change. Data were collected through questionnaires administered to quality improvement teams and group discussions.ResultsThe mechanisms for sharing ideas to improve the quality of services most commonly used are, in descending order: telephone communication (20 out of 34 sites), learning sessions (16 out of 34 sites) and visiting other sites (10 out of 34 sites). Few sites exchanged ideas through physical means (paper) or electronic media.Quality improvement teams reported preferring telephone communication as it provides quick, discreet, practical, and direct contact. On the other hand, some reported that telephone communication is costly, and does not allow direct contact or enough time to share experiences.With regard to learning sessions, sites believe that they are inexpensive and practical (i.e. the sites do not spend money to attend sessions), facilitate direct contact, provide an explicit mean of communication and allow more time to share experiences. Those who used learning sessions to share ideas reported that the “commitment of colleagues” is the main factor facilitating its use.Quality improvement teams that opted to visit other sites reported that these visits allow them to have a better understanding of the change implemented as well hands-on application.The majority of sites reported that the two main factors limiting use of a mechanism are: first, these mechanisms are not organized, and second, a lack of financial means or logistical support. Sites reported that external support played an important role in the use of various sharing channels and in the uptake of change ideas.Overall, many changes have yet to be disseminated. Of the 9 changes for PMTCT care documented in this study, only four have been implemented in more than half the sites. For ART treatment, only 5 of 8 changes are implemented in the majority of sites. Changes with a low rate of implementation include daily stock inventory, accompanying patients to their homes and displaying the ART regimen.Conclusions and RecommendationsThis study is one of the few studies that have investigated the diffusion of new ideas within a collaborative. It has shown what sharing mechanisms are the most commonly used by demonstration sites to share experiences. Thus, to facilitate the dissemination of good practices, the following actions are recommended:
- Provide logistics support to sites in order to facilitate telephone communication
- Provide internet connection to facilitate sharing of experiences via the internet.
- Organize regional learning sessions.
- Develop a directory of contacts and create a forum for exchange.
- Encourage sites within the same geographical area to visit neighboring sites to share experiences.
Effective sharing of improvement practices among members of the health system can lead to rapid and effective improvement across all sites. It would be important to assess the changes that may have occurred since the end of this study and determine whether sites that have heard of the changes implemented in other sites, have tried to implement them in their own sites. The lessons learnt from this evaluation should be applied to the spread phase to ensure that the learning process is strengthened. -
Effects of participating in collaborative improvement on the quality of HIV/AIDS care in facilities in Cote d’Ivoire: a comparison of intervention and control sites
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Collaborative improvement is one approach being used in many countries to improve prevention of mother to child transmission (PMTCT) and treatment with anti-retroviral therapy (ART) services. Collaborative improvement is consists of a network of teams engaging in a structured effort to learn from one another. A recent study analyzing the experiences of 27 collaboratives in 12 countries has shown collaborative improvement’s potential in achieving significant improvements in the level of the quality of care and the sustainability of such results. However, this is one of the first studies in developing countries that examines the effect of collaborative improvement in comparison to a control group.The Ministry of Health of Cote d’Ivoire and the USAID Health Care Improvement Project (HCI) launched a collaborative improvement initiative in December 2008, in collaboration with implementing partners. The collaborative operated in two phases: the initial demonstration phase, which began in January 2009, and the extension (spread) phase, initiated in August 2010. This collaborative provided an opportunity to: 1) examine whether there is a significant difference in the level of the quality of care between sites that have participated in an improvement collaborative versus those sites that will be in the extension phase and have therefore not yet participated in the collaborative activities; and 2) identify the factors contributing to this difference (if any) in the quality of care provided in the intervention and control sites.MethodologyThis study uses a modified quasi experimental design, in which the intervention group includes those sites participating in the demonstration phase of the ART/PMTCT collaborative, and the control group is composed of spread sites which had not yet been exposed to the collaborative activities but were planned to be included in the spread phase. Data were collected from 36 of the original 41demonstration (intervention) sites, and 42 spread (control) sites.ResultsIntervention sites saw significantly more improvement in quality of care indicators than control sites for completeness of documentation for PMTCT and ART, and for testing of children born to HIV+ mothers. Complete documentation for PMTCT at intervention sites rose from 22% at baseline to 83% after the collaborative, whereas at control sites during the same period there was only an 8% increase (from 0% to 8%); Complete documentation for ART at intervention sites rose from 22% at baseline to 87% after the collaborative, control sites had a higher baseline at 46% but this indicator barely showed any improvement at the end of the year (49%). Testing of children born to HIV+ mothers also increased at intervention sites. Results related to loss to follow-up for intervention sites do show initial improvement but some of the gains were lost towards the end of the study period. However, control sites experienced significant increases in loss to follow-up over time. Data availability was significantly lower in control sites than in intervention sites.QI competency and implementation were significantly higher in the intervention group, as were having a standardized process that would allow maintaining gains, mechanisms for orienting new staff, and systems for ensuring resource availability. Few differences in resource availability were noted. Control sites had a higher percentage of clinically trained providers. Intervention sites were likely to have generated change ideas themselves or borrowed these ideas from other participating sites rather than control sites, which, if they implemented the change, were mostly likely to have received the idea from their implementing partner.Regression analyses, holding other independent variables fixed (resources and clinical competence), showed a strong association between being involved in the collaborative and results related to documentation and testing of children born to HIV+ mothers.Conclusions and RecommendationsThis study has shown that facilities involved in collaborative improvement are able to achieve significant improvement over their own baseline results in comparison to sites that have not participated in a collaborative. Regression analysis indicates a strong association between being involved in the collaborative and improved documentation and increased testing of children born to HIV+ mothers. Time series charts also indicate potential impact on loss to follow-up, although the results were not as well maintained over time. This study is one of the first of its kind in a developing country to demonstrate the effects of participating in collaborative improvement on results achieved in comparison to a control group.
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Assessing Quality Improvement Team Performance on the HIV/AIDS Service Improvement Collaborative in Cote D'Ivoire
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High-perfoming quality improvement teams are the cornerstone for identifying and testing local strategies to improve care. This study was conducted in the context of a collaborative improvement initiative launched by The Ministry of Health of Cote d’Ivoire and its National Program for HIV Care and Treatment (PNPEC) and the USAID Health Care Improvement Project (HCI) in December 2008 to study the performance of quality improvement teams.
The main objective of this study was to assess the performance of teams in four areas of quality improvement. a) documentation of QA activities; b) analysis of the effectiveness of the changes tested; c) sharing results and lessons learned, and d) institutionalization of the care process. Insights from this study can be used to devise strategies to improve QI team performance and thus achieve greater gains in improvement.MethodologyThis cross-sectional study measured QI team performance in 33 sites in the demonstration phase of the PMTCT/ART improvement collaborative. Data was collected through interviews with QI team members, compiling QI team monitoring data, and a coach’s assessment of team performance.ResultsIn the 33 sites surveyed, for 63% of the tasks, there were at least three people in the QI team who knew how to perform the given QI task. Of the 33 teams, there were only three teams where there wasn’t at least one person competent enough to complete all 14 activities. The most challenging tasks were: implementing a PDSA cycle; and drawing, annotating, and interpreting time-series graphs.Overall, the level of team commitment, team collaboration, and resource availability was found to be relatively high. General Hospitals often reported having more resources than other health facilities, but they showed a relatively lower level of collaboration. There was no difference between those providing PMTCT services and those providing ART in these areas.Only 7% of sites can document the problem and improvement targets, record the indicators, make a plan of action and note the changes tested at the site in a complete and consistent manner. Forty-three percent of the sites did not use time series charts to monitor data and 68% of the sites did not annotate key changes on the time series charts. But most sites (68%) were able to discuss the factors that were behind the trends in the indicators and 64% of the sites were able to discuss next steps based on the data at hand. About half the sites were able to assess the impact of recent changes in care. Although most sites (96%) reported sharing their changes and results, more than 50% of the sites did this at a below satisfactory level. This was reflected in the finding that use of information received from other sites to improve care was satisfactory only in 25% of the sites.The degree of institutionalization was found to be low. Although almost 80% of the sites had developed some mechanism to orient new staff, more than 60% of the sites had not developed standard care processes including continuous quality improvement; a strategy to ensure resource availability, or a system for recognizing good performance. In each of the topics (Documentation, Analysis, Sharing, Institutionalization) PMTCT sites have relatively higher scores than ART sites.Conclusions and RecommendationsOverall the level of documentation and sharing was fair but analysis skills and development of mechanisms to enable institutionalization was low. This study identified specific areas of weakness in team performance. According to these results, it is desirable to give sites further support in working towards institutionalization of quality improvement activities. Also, coaching visits and learning sessions should provide greater training in drawing and annotating time series charts and also in analyzing data. Coaches can focus their efforts on the areas of weakness identified by this study during future site visits and learning sessions. -
Synthesis of Findings and Learning from the Field Testing of Learning System Tools: The Standard Evaluation System (SES) Team Documentation Journal, Team Synthesis Form, and Excel Results Databases
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In 2008, the USAID Health Care Improvement Project (HCI) took on the challenge of improving the learning system for health care improvement. This learning system includes the processes of harvesting, analyzing, and synthesizing knowledge about what teams do to improve health care and the process of sharing what they learn with other QI teams. Using experience to date and some innovations, HCI developed a set of four tools—collectively known as the “Standard Evaluation System” (SES) tools—for teams and their coaches to use to facilitate these knowledge management processes. The SES tools include a QI team-level Journal, a QI team-level Synthesis Form, and two databases for results indicator data—one for QI teams and the other for the collaborative level. These tools were created to help support the collaborative learning system by which teams examine which of their changes were most effective and sharing this learning with other teams in the collaborative. This report summarizes the results of testing these SES tools to strengthen documentation, analysis, and sharing of QI team efforts to improve care through testing of changes.
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PEPFAR | Care that Counts: Improving the Quality of Programs for Orphans and Vulnerable Children
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Lessons Lessons learned from OVC programs have revealed the need to improve service quality and to strengthen harmonization across partners around the questions: How can our programs make a measurable difference in children’s well-being? What are the essential actions that we all agree need to be part of a service to best to mitigate the impact of HIV/AIDS on children and families, in the pursuit of efficiency, effectiveness, equity, reach, and scale and sustainability? In response to the observed need to improve the quality of services provided to orphans and vulnerable children, in 2007, PEPFAR, through the United States Agency for International Development (USAID), sought to create a regional initiative to support countries and implementing partners in improving the quality of OVC programming. With support from the USAID Health Care Improvement Project (HCI), a regional OVC quality improvement initiative was organized. The initiative, which has come to be known as Care that Counts, has engaged national stakeholders, program implementers, and donor agencies throughout sub-Saharan Africa in improving the quality of OVC programming.
This short report describes the efforts of the Care that Counts Initiative to support to implementers at the country level to:
1) Build constituencies and commitment for quality in OVC programming,
2) Develop OVC service standards through consensus processes involving key stakeholders, including children and their families,
3) Undertake quality improvement activities at the point of service delivery with community-based volunteers and organizations, and
4) Gather evidence that standards and other quality improvement approaches have a measurable impact. -
Improving the Quality of HIV and AIDS Care and Related Services in Cote d'Ivoire
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This short report describes assistance that the USAID Health Care Improvement Project is providing to the National Program for HIV Care and Treatment (PNPEC) of the Ministry of Health, implementing partners, the National Program for Orphans and Vulnerable Children (PN-OEV) and the Ministry of the Family, Women and Social Affairs (MFFAS) in Cote d'Ivoire to apply improvement methods to improve the quality of antiretroviral therapy services, PMTCT, OVC programs, and peer prevention of HIV. The report also highlights results from 41 sites that have been engaged in an improvement collaborative on ART and PMTCT since 2008.
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Assessment of HIV Quality of Care in Cote d'Ivoire
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The assessment, conducted in July and August 2008, collected data from interviews with providers or heads of HIV services, as well as cohort data from medical records and registers used for prevention of mother-to-child transmission (PMTCT), voluntary counseling and testing (VCT), antiretroviral therapy (ART) and HIV care services. The first cohort, made of patients already on ART, was defined as patients who had a documented ART initiation date in their medical records as of June 2007. The second cohort, the "pre-ART" cohort, consisted of patients who had tested HIV-positive, were in HIV care, but who had not initiated ART in the first three months of HIV care. A third cohort was drawn from PMTCT registers and consisted of prenatal care clients who had tested HIV-positive and for whom data might be available for a potential period of 18 months.
The assessment found that for both the pre-ART and the ART cohorts, adherence to standards of care during the initial visit at the assessed sites was good. It was better among ART patients compared to pre-ART patients, and generally better among children compared to adults. Basic HIV care standards of HIV typing, weighing, clinical staging, and CD4+ T cell count assessment were all performed in at least 65% of patients. Adherence to standards of care was lower in the second semester of care for both cohorts. A number of clinical activities that were not conducted during clinical visits represent low-effort opportunities for providing care, including clinical staging, weight-taking, and patient counseling. Retention of patients in HIV care was found to be poor. Six months after initiating care, two out of three pre-ART patients and 45% of ART patients were lost to follow-up, comparing unfavorably with retention figures from other studies in the African context. While some sites worked with local groups providing community HIV care, coordination of this care was a challenge.
Reliance on information documented in medical records and registers limited this assessment, which was illustrated when medical record data for the ART cohort patients were compared with pharmacy data.
In discussing the findings with the Ministry of Health and stakeholders in Cote d'Ivoire, the following actions were recommended to be implemented as part of a collaborative approach to quality improvement:§ Monitor a small number of quality indicators, especially indicators that track longitudinal care,§ Improve documentation and information systems for efficient information retrieval,§ Focus on addressing poor retention and medical record management, and§ Promote shared learning of innovations in HIV care, including task shifting experiences.
