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Retention in care
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Tanzania | Lindi ART/PMTCT Collaborative
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Collaborative Profile
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Improving enrolment of HIV+ pregnant women in chronic HIV care/ART units at health facilities in Uganda
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Publications
HCI is working on improving the linkage of HIV+ pregnant women to chronic HIV/PMTCT services in 19 health facilities in the Eastern region of Uganda. Quality improvement teams at these sites will test changes aiming to improve these linkages. The effectiveness of these changes will be monitored by selected indicators. Changes that are found to be successful based on monitoring the indicators will then be shared across all 19 facilities. It is expected that by the end of the demonstration period there will be a list of effective changes that can then be spread to more facilities across Uganda.
Research QuestionsThis cross-sectional pre/post evaluation seeks to evaluate the scale of linkage problems, identify their causes, and inform health facility interventions to improve the linkages between ANC and chronic care for HIV+ mothers. The specific study questions are:1. What proportion of HIV+ pregnant women registered in ANC units at health facilities are enrolled into chronic HIV care units?2. What mechanisms do the health facilities use to ensure successful linkage of HIV+ pregnant women to HIV care clinic?3. What factors do pregnant or recently (6 months) delivered women report that promoted their successful enrollment into chronic care from ANC units? -
Tanzania | Tanga Region ART/PMTCT Improvement Collaborative
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Collaborative Profile
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Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative
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Collaborative Profile
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Feasibility of Using Quality Criteria to Monitor and Improve the Quality of HIV Services
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Publications
This short report describes assistance that the USAID Health Care Improvement Project (HCI) is providing to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and to the Office of the Global AIDS Coordinator (OGAC) to develop an approach that can be used to harmonize global reporting and improve the quality of HIV services and health outcomes. This study details HCI’s approach that employs 16 quality criteria for 5 HIV service delivery areas: testing and counseling, care and treatment, PMTCT, TB/HIV, and harm reduction. Field tests were conducted in five selected countries: 3 in Africa, 1 in Eurasia and 1 in Southeast Asia.
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IMPROVING PATIENTS' RETENTION IN HIV CARE THROUGH ADHERENCE TO SCHEDULED APPOINTMENTS AT BUKEDEA HEALTH CENTER IV, EASTERN UGANDA
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Publications
This poster, presented at the Global Health Council international health conference on June 14, 2011, describes the improvement story written by Mr. Okiror which won the "Best Improvement Report" contest conducted by the USAID Health Care Improvement Project in April 2011.
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Stephen Okiror of Bukedea Health Center in Uganda Wins Best Improvement Report Contest
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Soroti District Improvement Report
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Improvement Report
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Instruction Manual for Implementing a Gaps Analysis Framework to Guide Quality Improvement Decision-making in ART Programs
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Publications
A major function of the USAID Health Care Improvement Project (HCI) is to develop and validate methods for strengthening the capacity of health systems to provide and sustain high quality HIV/AIDS services. The quality improvement framework used to guide these activities recognizes that the fundamental objectives of HIV/AIDS programs should be to: 1) provide services for all who need them, 2) retain all those who access services in the continuum of care, and 3) achieve optimal health outcomes for all those who are retained in care.Due to the great clinical complexity of HIV/AIDS and of the issues associated with it, many process indicators have been generated in the HIV/AIDS field to monitor and evaluate the quality of treatment programs. This multitude of indicators can make the identification of priority areas for quality improvement very difficult and lead to QI activities that do not always address key program weaknesses. In 2009 HCI began testing the Framework for Quality Improvement in Chronic Care of HIV to guide quality improvement activities for HIV/AIDS treatment programs. The Framework offers an approach, for identifying and prioritizing problems and for evaluating the long term effects of changes, that is grounded in the overall program outcomes for: coverage of eligible persons, retention of patients in treatment, and clinical outcomes for patients in treatment. These outcomes are defined by a small set of indicators which expose outcome “gaps” by comparing potential to actual numbers of people with HIV who: 1) receive treatment, 2) are retained in treatment, and 3) achieve good clinical outcomes. At pilot sites, the framework has been useful for guiding HIV treatment programs in choosing their QI priorities and in monitoring overall program improvement.This manual describes the method for setting up the framework. Some or all of the data needed for this framework may be readily available, or information systems may need to be improved in order to gather necessary data. The meaning of the “gaps” quantified through this framework can also vary depending on the situation, and this should be taken into account in measuring, interpreting and addressing gaps in coverage, retention and clinical outcomes. Gaps may take long periods to decrease or close. Short term quality improvement decision-making therefore should not simply be based on the information in this framework. Rather, the framework should be used for long term program monitoring and decision-making, while specific process and/or intermediate outcome indicators, chosen to address one or more of the three outcome gaps described in this framework, should be used to track and make short term QI decisions.A related tool for the use of the ART Gaps Framework is the ART Framework Coverage Calculator, a Microsoft Excel spreadsheet that provides a practical way for estimating ART need in a population. The coverage calculator may be downloaded from the link below.
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Chronic Care Design Meeting: Transforming Health Systems and Improving Quality Care for Chronic Conditions in Africa
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Publications
As patients throughout Africa are living longer with chronic conditions such as HIV, hypertension and diabetes, health systems must adapt to meet their needs. Chronic conditions are defined as those with which patients live for many months or years. This report details the discussions and conclusions of a Chronic Care Design workshop held in Uganda to explore how to improve care for these conditions, focusing on HIV, in Africa. Officials from the Ministry of Health of Uganda, the United States Agency for International Development (USAID), USAID Health Care Improvement Project (HCI), and experts in HIV and chronic care, participated in this three-day workshop held at Speke Resort, in Munyonyo, Kampala, Uganda from May 26-28, 2010.As Uganda has been a leader in HIV care for African nations—exhibited in its implementation of programs such as the Ministry of Health Quality of Care Initiative in HIV and AIDS—its health system is optimal for analyzing the current and future ability to respond to chronic care conditions.During the three-day meeting, about 50 participants engaged in group work, discussions, and presentations in order to understand the current Ugandan chronic care system and how it can be improved and adapted to better care for patients with long-term illnesses and medical conditions.
Conclusions from the workshop and success stories from Uganda were presented on May 31, 2010, the first day of a four-day international conference on “Transforming Health Systems and Improving Quality Care for Chronic Conditions in Africa,” held in Kampala. More than 250 participants from 10 African countries (Cote d’Ivoire, Nigeria, Ethiopia, Rwanda, Kenya, Tanzania, Namibia, Malawi, South Africa and Uganda) gathered at the Imperial Royale Hotel in Kampala, Uganda and listened to highlights from the chronic care design meeting and learned how to redesign a health system to meet chronic care conditions in their home countries.
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IMPROVING QUALITY OF CARE IN RURAL HIV CLINICS THROUGH CLINICAL DATA AUDITS: EXPERIENCE FROM NORTHERN NIGERIA.
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Improvement Report
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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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Publications
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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Publications
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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Publications
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. -
The Framework for Engagement into HIV Care: A Tool for Strengthening the Health System's Response to the HIV/AIDS Epidemic in St. Petersburg, Russia
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Publications
Since 2004, teams of providers from the City AIDS Center, district polyclinics, TB facilities, and PLWH organizations in St. Petersburg, Russia, have worked together to analyze and improve the HIV/AIDS care system. Using an improvement collaborative process, key changes were introduced initially in a pilot district, and in 2008 began to be scaled up in all 18 districts of the city, including creation of a common database on HIV patients accessed by the AIDS Center and polyclinics, establishment of streamlined patient referral mechanisms between polyclinics, the City AIDS Center, and TB dispensaries; and operationalizing an algorithm for enrolling HIV patients in medical follow-up at the polyclinic level. This short report describes one product of this effort, the “Framework for Engagement into HIV Care”. This tool addresses enrollment and retention in the HIV/AIDS care system by defining a continuum of engagement of HIV-infected people into the system. By tracking target populations along this continuum to quantify gaps in service uptake and patient retention, the interventions needed to close these gaps become clear. The framework is the basis on which many improvement interventions were designed and implemented. Examples include: improved accessibility to substance abuse treatment for intravenous drug users, development of a state social service system for HIV patients, algorithms for polyclinic follow-up of HIV patients, and institutionalized training of providers on HIV counseling and testing. Enrollment and retention of HIV patients at polyclinics have greatly increased as a result of these interventions.
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Implementing a Gap Analysis Framework to Improve Care for Patients on ART: Training Participant Manual
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Publications
This quality improvement (QI) training participant manual was developed for presentation at a skill-building workshop conducted by the USAID Health Care Improvement Project at the June 2010 Global Health Council annual conference. The workshop was designed to develop participants’ knowledge and skills in modern health care improvement, including aim-setting, indicator development, process analysis, and developing tests of changes using Plan-Do-Study-Act (PDSA) cycles for implementing improvement interventions.
The workshop includes the slides for a series of short presentations and exercises to enable participants to practice steps in the QI process with a case study example on reducing gaps in coverage, retention in care, and clinical outcomes for HIV-infected patients on antiretroviral therapy (ART).
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Improving Care for Patients with HIV
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Uganda – Retention Collaborative
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Collaborative Profile
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Uganda – HIV/ART Coverage Collaborative
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Collaborative Profile
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Assessment of HIV Quality of Care in Cote d'Ivoire
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Publications
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.
