HIVQUAL: A Model for Building Capacity to Improve the Quality of HIV Health Care in Emergency Plan C

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HIVQUAL A Model for Building Capacity to
Improve the Quality of HIV Health Care in
Emergency Plan Countries
Developed and implemented by the New York State
Department of Health AIDS Institute
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What is HIVQUAL?

• HIVQUAL is
• A capacity-building model to build capability for
  quality improvement in HIV health care facilities
  that is designed to improve care for people
  living with HIV
• A simple, systematic way to monitor HIV/AIDS care
  using a sampling strategy that promotes
  self-assessment through record review
• An approach to quality management with three core
  components
• Performance measurement
• Quality improvement
• Infrastructure support for quality management

3
How Was HIVQUAL Developed and Where Is It Used?

• The HIVQUAL model is based on standards and
  methods from the New York State Department of
  Health AIDS Institutes HIV Quality of Care
  Program which was launched in 1992
• This model was adapted for use in HIV ambulatory
  care clinics across the U.S. through HRSA and is
  currently used in over 160 clinics
• HIVQUAL has been adapted for international use
  it has been successfully implemented in Thailand
  since 2003 and is now being launched in Uganda
  (2005) as well as Mozambique and Namibia (2006)

4
Why Quality Improvement?

• Quality improvement focuses on improving systems
  of healthcare delivery not looking for
  deficiencies
• QI methods
• Use reliable performance data
• Minimize variation in the delivery of healthcare
  services
• Involve the healthcare team in implementing
  changes
• Emphasize effective use of limited resources
• Improve processes of health care that result in
  desired health outcomes
• Support implementation of national guidelines and
  accreditation standards

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What are the HIVQUAL Methods?

• Implementation of QI Projects
• Focus on selected aspects of ambulatory care with
  ongoing measurement of core indicators selected
  in each country
• Coaching tailored to the needs of individual
  clinics
• QI infrastructure development
• Regional workshops to share best practices,
  barriers and successes of QI projects
• Performance measurement based on a sampling
  methodology with customized software available
  for self-reporting of data

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Philosophy of HIVQUAL
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Philosophy of HIVQUAL
Infrastructure
8
Performance Measurement
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Performance Measurement

• HIVQUAL provides a systematic methodology for
  measuring the quality of care in clinical
  settings by
• Defining core indicators based on national
  guidelines with MOH
• Abstracting charts from a randomized sample of
  patients
• Establishing a baseline level of performance
• Using performance data to identify QI needs and
  drive improvement priorities and strategies
• Monitoring progress over time

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Performance Measurement Indicators

• Selected by each participating country based on
  national guidelines
• Core set of indicators for initial implementation
• Reasonable number of measures
• Balanced package
• Report twice yearly
• Selection criteria include relevance,
  measurability and improvability

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HIVQUAL-Uganda Indicators

• Continuity of Care (Patient Retention)
• Clinic visits every 3 months
• HIV Monitoring
• CD4 counts every 6 months CD4 count in last 6
  months
• ARV Therapy
• Adherence to ARV Therapy
• Documentation of adherence assessment
• Cotrimoxazole
• TB Screening in the last 3 months
• Prevention Education

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Performance MeasurementSampling Table

• Sample size based on caseload to achieve
  precision of 95 CI 8
• The HIVQUAL Sample Size Chart indicates
• The minimum number of records to be reviewed, and
  
• The number of records to be pulled to allow for
  over-sampling.

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HIVQUAL Project Software

• MS-Access package
• Immediate reporting of performance data for use
  in developing QI
• Indicators measure HIV care with prompted screens
  based on algorithmic logic for data entry
• User-defined fields
• Data can be exported into HIVQUAL software
• Can produce data from other software packages

Reporting can be also be achieved using paper
forms data abstraction
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Interpreting Performance Data

• Providers are encouraged to analyze data and
  assess internal factors that contribute to their
  organizational performance
• Longitudinal trends
• Benchmarking

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Performance Measurement Benefits

• Improves systems for documentation
• Improves accuracy of developing case lists
• Builds skills for interpretation of data
• Leads to development of more comprehensive data
  systems

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Quality Improvement
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Why Quality Improvement?

• Its about implementation

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Why Quality Improvement?

• Its about systems

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Why Quality Improvement?

• Its about using performance data in the clinic
  and by the clinic staff

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QI Principles

• Measurement Use data to improve care
• Focus on the important patient outcomes and
  consumer needs
• Involvement of participants encourage direct
  participation in teams by those individuals who
  implement the processes being evaluated
• Enhance communication accountability
• Emphasis on strengthening systems of care through
  analyzing and processes

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QI Models and Tools

• Model For Improvement
• HIVQUAL Project
• Flowcharting
• systems analysis

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Quality Improvement Projects

• Prioritize area for improvement based on
  performance data
• Develop project workplan
• Identify the sequential processes of
• the chosen system
• Choose changes to test
• Implement changes
• Remeasure
• Modify as needed
• Integrate improvements into daily work
• Share strategies best practices

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Infrastructure
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Infrastructure

• Organizational assessment to track development
  and sustainability of quality management program
• Components include planning, QI structure, QI
  program evaluation
• Analysis through self-assessment tool and
  external evaluation with explicit scoring
  criteria
• Guides QI program development
• Identifies coaching priorities

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Implementation Coaching

• Method introduced in-country by experienced
  US-based team to build capacity for coaching by
  HIVQUAL team
• Strengthens infrastructure to support quality
  management
• Emphasizes planning and QI projects including
  rapid cycle tests of change
• Supports performance measurement
• Facilitates improvement of documentation systems
  to support care

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Implementation Staffing and Consultation

• US team provides consultation and mentors
  in-country team
• Visits to conduct education, onsite assessments,
  facility coaching
• In-country staff provides facility-based
  coaching, technical support for data collection,
  data reporting
• Each country has a HIVQUAL lead working in
  consultation with Director and in-country team
• Visits to US by in-country team

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HIVQUAL-T
An Innovative Performance Measurement Tool for
HIV Care Quality Improvement in Thailand

• Somsak Supawitkul1
• Rangsima Lolekha1
• Saowanee Srisongsom1
• Suchin Chunwimaleung1
• Sombat Thanprasertsuk2
• Nicole Simmons1
• 
  Bruce D. Agins3
• Robert N. Gass3
• Kimberley Fox1,4
• Jordan W. Tappero1,4
• William C. Levine1,4
• 1Thailand MOPH U.S. CDC Collaboration, Thailand
• 2 Bureau of AIDS TB and STIs, Ministry of Public
  Health, Thailand
• 
  3New York State DOH AIDS Institute,
  USA
• 
  4
  HHS/CDC Global AIDS Program, Atlanta, GA, USA

Infrastructure
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Thailand

• Area 513,115 sq km
• Population 2002 63,400,000
• Per capita income (2004) 2,578 US

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HIV/AIDS Epidemic in Thailand

• Cumulative HIV infections (2005)
  1,092,327
• Persons living with HIV/AIDS (2005)
  540,822
• New HIV infection (2005) 18,172
• Heterosexual transmission accounted for 70 of
  HIV infections in 2005
• 34 of cases are female
• Prevalence rate among IDUs is 40
• gt65,000 people receiving ARV
• Single dose HAART (GPOvir)

Source The Thai Working Group
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Chronology of HIV Medical Care
1. 1984 Treatment of common opportunistic
infections
2. 1992-1995 Monotherapy (AZT)
3. 1995-1996 Dual therapy (AZT ddI and AZT
ddC)
4. 1997-2000 HIV Clinical Research Network (dual
and triple ARV)
5. 2001 Access to Care (triple ARV and OI
prevention and treatment)
6. 2002 Expand Access to Care Begin scale-up
7. 2006 Integration of ARV treatment into
National Health System
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Existing HIV care system

• Core national organizations
• Policy/guidelines BATS, Medical Services
  Department
• Budget and resources National Health Security
  Office (NHSO) and Social Security Office (SSO)
• Quality accreditation Institute for Quality
  Improvement and Hospital Accreditation (IQIHA)
• Service delivery organizations
• Government
• MOPH BI, departmental hospitals,
  regional/general/community hospitals, and
  community health centers, BMA hospitals
• University hospitals
• Private hospitals

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HIVQUAL-T Project Initiation

• Opportunity for QI consultation identified during
  I-TECH assessment - 2002
• Engagement January 2003
• Site visits and planning March 2003
• Implementation of Pilot 2003-4

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HIVQUAL-T Project Development

• Indicators chosen
• Paper abstract forms developed
• Criteria defined
• Site visits baseline assessments
• August 2003
• Software programmed in Thai
• Initial staff training
• December 2003

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Getting Started

• I-TECH assessment underscores need for quality of
  care program
• KEY POINT Linkages of HRSA-sponsored program
• Identification of key point person in GAP office
• KEY POINT Coordination between USG partners in
  US and GAP office in-country essential
• Funding available locally to support initial
  visit
• KEY POINT Initial work might precede COP
  planning

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HIVQUAL-T Goals

• Develop a sustainable QI program structure that
  supports ongoing improvement in the quality of
  HIV care
• Promote reporting of HIV care performance data by
  hospitals
• Improve the quality of care for PLHA

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HIVQUAL-T Indicators

• Core Indicators
• CD4 testing
• Opportunistic infection (OI) prophylaxis
• ARV therapy
• TB Screening
• STI screening
• Care of women Pap smear
• Revisions
• Adherence measurement
• Prevention education

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Development of HIVQUAL-T Software

• Working group meetings and hospital surveys
  initiated
• Indicators defined based on Thai National
  Guidelines (7th edition)
• Paper abstract forms developed
• Software developed

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HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2003-2004
1995-2005
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HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2005 57 piloted sites
2003-2005
1995-2005
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HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2005 57 piloted sites
2005 142 hospitals
2003-2005
1995-2005
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Monitoring HIV/AIDS care at provincial or
national levels

• Send HIVQUAL-T data to
• Provincial Health Office
• Ministry of Public Health
• Aggregate data and compare indicators at the
  hospital, district, provincial level
• Random sampling method makes comparisons
  statistically valid

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Report example provincial level
Percent of eligible PLHA on PCP prophylaxis by
hospital, 2004
N 22 hospitals
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Results HIVQUAL-T indicators 2002-2005

• 2002 12 hospitals n546
• 2003 42 hospitals n670
• 2004 63 hospitals n790
• 2005 63 hospital n842

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QI project implementation Examples
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Results QI activities after data report

• Examples of specific QI activities
• Developed HIV care check list and flow charts for
  physician and nurse
• Improved HIV database system
• Educated patients on the importance of Pap smear
  and STI screening for HIV infected women
• Educated care providers and patients on the
  importance of CD4 testing, OI prophylaxis, TB
  screening and ARV treatment

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Example QI development in one hospital

• Developed HIV-QI working group in the hospital
  and assigned persons responsible for QI project
  implementation
• Provided training update for care providers on
  HIV treatment and care
• Provided information on cervical cancer and Pap
  smear screening among PLHA attending HIV peer
  group activities and referred patients to receive
  Pap smear in the hospital
• Provided treatment to patients with abnormal Pap
  smears

Developed QI process
5 of 56 abnormal cases
TB screening
CD4 test
Pap smear
Example from Mae Lao hospital
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Quality Improvement Education

• Coaching
• Workshops
• Training
• Interactive hands-on exercises
• Regular provider meetings for peer learning and
  exchange of best practices

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Results Summary

• The quality of HIV care, based on Thai national
  guideline indicators, improved in several areas
  following implementation of HIVQUAL-T
• Important areas for ongoing QI activities
  include
• CD4 testing as the gateway to further HIV care
• OI prophylaxis
• Cervical cancer screening for HIV-positive women
• Collaboration with Ministry of Public Health and
  Hospital Accreditation agency to expand nationally

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HIVQUAL-T in the future

• Integration of HIVQUAL-T into national health
  insurance program (NHSO)
• Additional modules for HIVQUAL-T
• Pediatric HIVQUAL-T pilot underway
• PMTCT HIVQUAL-T
• Day care center HIVQUAL-T - implemented
• VCT HIVQUAL-T
• Group learning QI activities
• Complete organization assessment tools for QI
  infrastructure evaluation
• Develop HIVQUAL-T training websites

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Lessons LearnedKey Factors for Successful
Implementation

• RESOURCES
• Donor Country buy-in
• Support from GAP office
• Coordination with Ministry of Health
• Alignment of priorities and with GFATM
• IMPLEMENTATION
• Local leadership and staff
• MOTIVATION
• Commitment to quality
• Thai culture and professional ethos

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Summary HIVQUAL-T

• Magnitude of HIV epidemic and complexity of
  treatment make quality assessment of HIV care
  essential
• HIVQUAL-T provides a simple, systematic way to
  monitor HIV care using a sampling strategy
• Local analysis of data can be used effectively
  for quality improvement
• Data can be aggregated for monitoring and
  evaluation at provincial and national levels to
  inform policy and planning
• HIVQUAL can be adapted from one country to
  another, adjusting for differences in guidelines,
  resources, and health care models

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Sustainability of HIVQUAL-T and QI process in
Thailand

• Integration with other activities such as
  hospital accreditation, national health security
  office, national HIV program ME
• Receive strong leadership commitment from
  Ministry of Public Health and hospital staff

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From Thailand to U.S.

• Consumer card
• Emphasizing case lists the denominator
• Mortality review
• Outcomes justify the indicator prevalence rates
• Single-payor healthcare system Government public
  health leadership
• National Hospital Accreditation QI
• Streamlined software- and international version
• Thai work ethic

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H I V Q U A L U G A N D A
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What is Unique About HIVQUAL Uganda?
-Continuity of Care (Patient Retention) -Clinic
visits every 3 months -HIV Monitoring -CD4
counts every 6 months -CD4 count in last 6
months -ARV Therapy -Adherence to ARV
Therapy -Documentation of adherence
assessment -Cotrimoxazole -TB Screening in last
3 months -Prevention Education

• Staffing inside the MOH
• The indicators
• Regional groups
• Multiple donors
• QAP collaborative

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From Uganda to U.S.

• Regional coordination
• Prevention package
• Its our problem

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HIVQUAL MOZAMBIQUE
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Whats Unique about HIVQUAL Mozambique?

• Healthcare worker shortages working with Track 1
  partners
• Staffing options limited to manage project work
  with implementing partner JHPIEGO
• Indicator
• Add indicator addressing Pep practices

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From MZ to US

• Too soon to tell

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H I V Q U A L N A M I B I A
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Whats Unique About HIVQUAL Namibia?

• MOH structure and staffing
• Starting off with COP planning and USAID
  coordination
• Indicators
• Food security?
• Alcohol screening?
• Geography
• Partnering with I-TECH

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From Namibia to U.S.

• Distance learning

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Implementing HIVQUAL International
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How is HIVQUAL Implementation Different in the
International Setting?

• Capacity-building occurs on two levels
• Healthcare facility
• National HIV Program
• Engagement of stakeholders involves consideration
  of project staffing in-country and is longer than
  period for engagement in domestic program
• Language may be an issue

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Evaluation Spread (1 2 months)
QI (3-6 months)

• Group meetings
• Peer learning
• Best practices
• QI projects
• Remeasurement

Pre-implementation Phase
Pilot (4 6 months)
Data-driven QI Projects QI training Coaching/TA

• Modify software
• Training (on-going)
• Coaching TA (on-going)
• Collect, analyze data

Planning (2 3 months)

• Stake holders
• Select indicators
• Select sites
• Assess sites
• Non-research status
• Staffing

Demonstration Phase
Engagement (1 2 months)

• Orientation
• Prelim discussions
• Site visits
• Logistics

3 6 9 12
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HIVQUAL Outcomes

• Improves the quality of HIV clinical services
• Builds capacity for measuring care and QI among
  healthcare workers
• Strengthens HIV QI infrastructure and
  documentation systems in HIV clinics
• Monitors implementation of national guidelines
  through benchmarking reports
• Identifies national priorities for policy and
  planning

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Summary

• HIVQUAL provides a simple, systematic method to
  monitor care, using a sampling strategy and
  building skills for self-assessment
• The HIVQUAL model is adaptable from one country
  to another, adjusting for differences in
  guidelines, resources and healthcare models
• Through HIVQUAL, program capability for improving
  quality is sustained following departure of donors

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Special Thanks

• Margaret Palumbo (Uganda, Mozambique)
• Jan King (Namibia)
• Robert Gass (Thailand)
• Tracy Matthews
• HRSA Global Team
• CDC Atlanta Care Treatment Team (La Mar
  Hasbrouck)
• HIVQUAL-T Team
• HIVQUAL-Uganda Team
• I-TECH

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For More Informationwww.hivqual.org

• Bruce D. Agins, MD MPH
• Director, International HIVQUAL Project
• Medical Director, NYSDOH AIDS Institute
• bda01_at_health.state.ny.us

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Acknowledgements

• Bureau of AIDS, TB, and STI, Thailand MOPH
• Office of Disease Control and Prevention
  Regions 10 and 7
• (Chiang Mai, Ubon Ratchathani)
• Provincial Health Offices
• Chiang Mai, Chiang Rai, Phayao, Ubon, Phuket, and
  BMA
• Thailand MOPH U.S. CDC Collaboration
• New York State Dept of Health AIDS Institute, USA
• HIV/AIDS Bureau, Health Resources and Services
  Administration, DHHS