Title: HIVQUAL: A Model for Building Capacity to Improve the Quality of HIV Health Care in Emergency Plan C
1HIVQUAL 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
2What 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
3How 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)
4Why 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
5What 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
6Philosophy of HIVQUAL
7Philosophy of HIVQUAL
Infrastructure
8Performance Measurement
9Performance 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
10Performance 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
11HIVQUAL-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
12Performance 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.
13HIVQUAL 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
14Interpreting Performance Data
- Providers are encouraged to analyze data and
assess internal factors that contribute to their
organizational performance - Longitudinal trends
- Benchmarking
15Performance 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
16Quality Improvement
17Why Quality Improvement?
18Why Quality Improvement?
19Why Quality Improvement?
- Its about using performance data in the clinic
and by the clinic staff
20QI 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
21QI Models and Tools
- Model For Improvement
- HIVQUAL Project
- Flowcharting
- systems analysis
22Quality 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
23Infrastructure
24Infrastructure
- 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
25Implementation 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
26Implementation 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
27HIVQUAL-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
28Thailand
- Area 513,115 sq km
- Population 2002 63,400,000
- Per capita income (2004) 2,578 US
29HIV/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
30Chronology 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
31Existing 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
32HIVQUAL-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
33HIVQUAL-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
34Getting 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
35HIVQUAL-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
36HIVQUAL-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
37Development 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
38HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2003-2004
1995-2005
39HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2005 57 piloted sites
2003-2005
1995-2005
40HIVQUAL-T implementation in Thailand
2004 12 piloted sites
2005 57 piloted sites
2005 142 hospitals
2003-2005
1995-2005
41Monitoring 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
42Report example provincial level
Percent of eligible PLHA on PCP prophylaxis by
hospital, 2004
N 22 hospitals
43Results HIVQUAL-T indicators 2002-2005
- 2002 12 hospitals n546
- 2003 42 hospitals n670
- 2004 63 hospitals n790
- 2005 63 hospital n842
44QI project implementation Examples
45Results 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
46Example 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
47Quality Improvement Education
- Coaching
- Workshops
- Training
- Interactive hands-on exercises
- Regular provider meetings for peer learning and
exchange of best practices
48Results 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
49HIVQUAL-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
50Lessons 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
51Summary 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
52Sustainability 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
53From 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
54H I V Q U A L U G A N D A
55What 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
56From Uganda to U.S.
- Regional coordination
- Prevention package
- Its our problem
57 HIVQUAL MOZAMBIQUE
58Whats 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
59From MZ to US
60H I V Q U A L N A M I B I A
61Whats 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
62From Namibia to U.S.
63Implementing HIVQUAL International
64How 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
65Evaluation 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
66HIVQUAL 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
67Summary
- 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
68Special 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
69For More Informationwww.hivqual.org
- Bruce D. Agins, MD MPH
- Director, International HIVQUAL Project
- Medical Director, NYSDOH AIDS Institute
- bda01_at_health.state.ny.us
70Acknowledgements
- 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