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Quality of Care at a Multi-site PEPFAR-funded ART Program: From Measuring to Improvement

Quality of Care at a Multi-site PEPFAR-funded ART Program: From Measuring to Improvement. Partner. Project HEART Background. Rapid growth of clinical programs and patient load

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Quality of Care at a Multi-site PEPFAR-funded ART Program: From Measuring to Improvement

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  1. Quality of Care at a Multi-site PEPFAR-funded ART Program: From Measuring to Improvement

  2. Partner

  3. Project HEART Background • Rapid growth of clinical programs and patient load • Initial emphasis on maximizing number of clients enrolled and started on ART and ensuring minimum quality of systems and care • Expansion of work to ensuring high levels of quality of care and building capacity for ongoing quality improvement

  4. Project HEART and Quality2004-2006 • Integrated quality management program to measure and provide support • Focused on baseline assessments and identifying urgent TA needs • Standardized approach including system assessments and chart review • Immediate feedback to sites

  5. Chart Review • Sites chosen by country staff • Charts randomly selected at site level • Baseline and care in prior 6 months data extracted • Data sources included the medical chart and pharmacy logs

  6. Quality of Care Indicators • Indicators reflect international standards and critical care and treatment areas • Included: • On cotrimoxazole if eligible • On ART if eligibility • TB screening • Adherence • Identified problems and adherence support • Missed visits and outreach • Disclosure and risk reduction discussions

  7. Population • Adults receiving HIV care at Project-HEART-supported sites between 2005 and 2006 • 935randomly chosen patients at 22 sites, with 708 patients (85%) alive and active in the program at the start of the review period.

  8. Population Characteristics

  9. Adherence to care and missed visits *documented in chart

  10. ART and Response *Response: clinical stability or improvement, no new OIs > 3months since ART start, gained weight or CD4 count improvement **If on >6 mos. Difference not significant

  11. ART and Adherence

  12. OI Prevention

  13. Risk Reduction and Disclosure Discussion

  14. Cross-country analysis • No disparities in care received seen by gender • Each country had strengths and areas of potential challenges • Some represented differences in quality • Others, differences in documentation or policies

  15. Inter-site variability • Significant variability across sites • Disclosure discussions • Risk reduction counseling • TB screening • Cotrimoxazole use • Provides opportunities for cross-site and inter-country sharing of best practices and lessons learned

  16. QI Case Study: Cote d’Ivoire • February 2007 QI visit at CAT Adjamé showed lower than expected adherence to follow-up visits. • Issue • Actual missed visits • Documentation of visits

  17. Site response • Reorganized medical record filing system to allow for easier chart access • Training regarding documenting visits in patient medical record • Enhanced pre-ART adherence counseling • Strengthened pharmacy counseling efforts • Follow up visit found extensive improvements in documentation • Next steps – focusing on outreach for missed visits

  18. QI Case Study: Tanzania • Issue: CD4 testing not done according to the national guidelines at Mawenzi District Hospital (MDH) • Of 45 patients reviewed, 38 (84%) had an enrollment CD4, and 19 (42%) had a CD4 during the last 6 months • Tests run only 2 days/week • Only 2 staff trained to run FACS

  19. Site Response • Tests run more routinely (4 days/week) • Refresher training about • Utilization of CD4 • The need to document CD4 test results Chart review pending

  20. Limitations of initial approach • Limited ability to revisit sites for change over time • Initial efforts to build capacity in-country overwhelmed by basic M & E demands • Different country level priorities for specific areas of concern vs measurement of overall quality.

  21. Challenges of Developing a Sustainable QM Program • How to expand to meet rapid growth of number of sites and geographic distance • How to build local capacity at the country program level • Heterogeneity of capacity at country and site level • IMPORTANCE OF TAILORING THE APPROACH • Need to harmonize with national or provincial programs (ex. South Africa, Mozambique)

  22. Quality Measurement and Improvement Expansion Phase • QM integrated into the overall program at central and country programs • Develop and Implement individualized Quality Management Program to support initiatives to improve care • Tailor approaches to meet needs and reflect existing capacity • Focus on capacity building • country level and then sites

  23. Implementation • Develop Project-wide core indicators • Develop country QM plans • Leadership, country-specific indicators • Training and capacity building at country level and pilot at site level • Didactic and practical training

  24. Conclusions • Despite rapid expansion, Project HEART-supported programs have delivered high quality of care in a number of areas • Varied challenges within and across countries • Fostering local ownership, capacity and sustainability is a challenge

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