strengthening uganda’s systems for treating aids ... · patients for art eligibility, ensure...

HIV CARE AND TREATMENT CHANGE PACKAGE

AUGUST 2017

The SUSTAIN project is made possible by the generous support of the American people through the United States Agency for International

Development (USAID) under Cooperative Agreement number 617-A-10-00007-00. The project team includes prime recipient University

Research Co., LLC (URC) and sub-recipients; The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI),

Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), Child

Chance International (CCI Uganda), AIDS Information Centre (AIC) and ACLAIM Africa.

Synthesis of the most robust and effective QI interventions to improve HIV Care and Treatment in SUSTAIN supported hospitals in Uganda

STRENGTHENING UGANDA’S SYSTEMS FOR TREATING AIDS NATIONALLY

HIV Care and Treatment Change Package i

Quality Improvement Change Packages Series

The purpose of the quality improvement change packages is to provide a

synthesis of the most robust and effective QI interventions for effective HIV

programming. The quality improvement change packages series thematic

areas include: prevention of mother to child transmission, laboratory, monitoring

and evaluation, adolescent friendly health services, voluntary medical male

circumcision, nutrition, HIV care and treatment, supply chain, Tuberculosis, and

quality improvement.

USAID/SUSTAIN acknowledges the work of the project staff, technical officers at

MoH, and counterparts at supported facilities who have been instrumental to the

project’s many successes through implementation of the quality improvement

interventions.

The publication and production of these change packages, as well as the work

of the SUSTAIN project, was made possible by the generous support of the

American people through USAID. The SUSTAIN project is led by University

Research Co., LLC and works in partnership with: The AIDS Support Organization

(TASO), Integrated Community Based Initiatives (ICOBI), Uganda Catholic

Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda

Muslim Medical Bureau (UMMB), Child Chance International (CCI Uganda), AIDS

Information Centre (AIC) and ACLAIM Africa, under Cooperative Agreement No.

617-A-10-00007-00.

The views and opinions expressed here do not necessarily state or reflect those of

USAID or the United States government.

HIV Care and Treatment Change Package iii

Contents

Quality Improvement Change Packages Series ..................................................... i

Acronyms ............................................................................................................ iv

Introduction ..........................................................................................................1

Harvest Meeting ...................................................................................................2

Change package for improving HIV care and ART services at

high-volume hospitals in Uganda .........................................................................5

Intended Use ..................................................................................................5

Improvement Aim 1: To improve the proportion of clients in HIV care

who are enrolled on ART to 95% by September 2016 at 11 Regional

Referral Hospitals and 1 General Hospital in Uganda .....................................6

Improvement Aim 2: Improve the proportion of HIV clients on

ART that are alive and well 12 months after initiating treatment ....................10

Improvement Aim 3: To improve the proportion of clients on

ART receiving viral load tests ........................................................................ 14

Key Challenges .................................................................................................. 17

Moving Forward .................................................................................................18

HIV Care and Treatment Change Packageiv

List of Acronyms

ART Antiretroviral therapy

CD4 Cluster of differentiation 4

CDC Centers for Disease Control and Prevention

CME Continuing Medical Education

DHIS2 District Health Information System, version 2

HC Health Center

MoH Ministry of Health

PMTCT Prevention of Mother to Child Transmission

QI Quality Improvement

RRH Regional Referral Hospital

SUSTAIN USAID Strengthening Uganda’s Systems for Treating AIDS Nationally

TB Tuberculosis

USAID United States Agency for International Development

VL Viral load

WHO World Health Organization

HIV Care and Treatment Change Package 1

Introduction

Since 2010, the United States Agency for

International Development (USAID) has been

working with Uganda’s Ministry of Health (MoH)

to improve HIV and AIDS service delivery at select health

facilities through the Strengthening Uganda’s Systems for

Treating AIDS Nationally (SUSTAIN) project. Over the last

seven years, the SUSTAIN project has aimed to:

n Support the MoH to scale up prevention of Mother-

to-child transmission of HIV (PMTCT) and voluntary

medical male circumcision (VMMC) as HIV infection

prevention interventions within selected public regional

referral hospitals (RRHs) and general hospitals

n Ensure provision of HIV care and treatment, laboratory

and tuberculosis (TB)/HIV services within selected

public RRHs, general hospitals and health center (HC)

IVs

n Enhance the quality of PMTCT, VMMC, HIV care

and treatment, laboratory, nutrition, supply chain

management, and TB/HIV services within selected

RRHs, general hospitals and HC IVs, and

n Increase stewardship by the MoH to provide

sustainable quality HIV prevention, care and treatment,

laboratory and TB/HIV services at project-supported

healthcare facilities.

In 2014, the MoH adopted the Joint United Nations

Programme on HIV/AIDS (UNAIDS) 90-90-90 strategy

that aims to have 90% of all people living with HIV know

their status, 90% of all people with diagnosed HIV

infection receive sustained antiretroviral therapy, and 90%

of all people receiving antiretroviral therapy attain viral

suppression, by 2020. The USAID/SUSTAIN project has

been supporting the MoH on the journey to 90-90-90

using quality improvement approaches, ongoing onsite

supervision and mentorship, and supply chain support

to ensure availability of commodities and supplies at 11

regional referral hospitals and one general hospital.

The USAID/SUSTAIN project has provided technical,

coordination and operational support to 12 hospitals in

Uganda to deliver high quality HIV care and antiretroviral

therapy (ART) services for both adults and children.

The project was designed to strengthen Uganda’s

decentralized health system, and provided continuous

capacity building opportunities for all stakeholders in the

health sector. The project worked with all levels of the

health system: Ministry of Health, district health officials,

health facilities, and at the community level.

Through off-site workshop training opportunities and

onsite mentorship and coaching sessions, and continuous

application of quality improvement approaches, hospital

staff have been supported to: improve access to HIV care

and nutrition services for HIV+ patients, improve enrolment

of newly identified HIV+ patients into care, screen pre-ART

patients for ART eligibility, ensure retention in treatment for

patients enrolled on ART, and monitor both immunological

and viral load (VL) changes for clients on ART.

The project’s approach to quality improvement (QI) was

guided by the Model for Improvement that uses the Plan-

Do-Study-Act cycles. HIV and ART experts from SUSTAIN

supported the formation of multi-disciplinary improvement

Table 1: List of Intervention Health Facilities

Name of Facility Level of Facility

Arua Regional referral hospital

Fort Portal Regional referral hospital

Gulu Regional referral hospital

Hoima Regional referral hospital

Jinja Regional referral hospital

Kabale Regional referral hospital

Kawolo General hospital

Lira Regional referral hospital

Mbale Regional referral hospital

Moroto Regional referral hospital

Mubende Regional referral hospital

Soroti Regional referral hospital

HIV Care and Treatment Change Package2

Harvest Meeting

After six years of project implementation, medical

officers, clinicians and senior nursing officers

from the 18 hospitals gathered for a harvest

meeting in August 2016 to reflect on their results,

discuss both successful and unsuccessful changes

ideas, and share evidence on which pathways resulted

in positive results. Guided by their experience in using

QI to improve HIV care and ART services, they agreed

on a set of best practices that could guide other hospital

teams to improve HIV services and as they advance

towards the 90-90-90 goal. Divided into small groups,

teams discussed the change ideas they had tested,

the steps they followed in introducing and testing these

changes, and the results they had observed that could

be attributed to the tested changes. During plenary

sessions, the changes were discussed further by a larger

and wider group of representatives, who also evaluated

and scored them based on relative importance, level of

simplicity and how scalable they were.

All the parameters (relative importance, simplicity and

scalability) were scored 1-5 by the participants. A

score of 1 (one) for any of the parameters meant the

change was not important, it was too complex and was

teams at all supported health facilities, through which

QI interventions were implemented. This improvement

collaborative approach, where teams work to identify

and address a myriad of challenges affecting the content

and processes of care, is consistent with the Ministry of

Health’s Quality Improvement Framework and Strategic

Plan. On a monthly basis, the improvement teams received

coaching and onsite supervision and mentorship on

how to identify gaps in care, how to prioritize areas for

improvement, and how to develop, test and eventually

implement change ideas that could lead to improvements.

a) ART initiation for eligible HIV+ clients,

b) retention of HIV+ clients on ART for more than 12

months, and

c) access to viral load monitoring among patients on ART.

Figure 1: Guide to interpreting the rating of change ideas

n Change was not

important

n Change idea was

too complex

n Change is

difficult to scale

n Only important

in a few aspects

n Change is often

complex

n Scalable with

significant

challenges

n Change can

be important

n Change can

be complex

n Scaling

requires effort

n Change was

important

n Change is

sometimes

simple

n Scalable with

limited effort

n Change was

very important

n Implementation

is always smple

n Change is easily

scalable

1 2 3 4 5


not scalable. A score of 5 (five) meant the change was

very important, or simple and/or scalable. The average

scores are presented in Tables 2–4. Tables 5–7 provide

a comprehensive list and description of all the change

ideas tested, with notes on the specific steps taken to

implement the change, the observed results and the

number of facilities (scale) that implemented the specific

changes.

Table 2: Rating of change ideas implemented to improve the proportion of clients in HIV care who are enrolled on ART

SN Change idea

Number of facilities

testing this change

Rating Criteria

Total score

Average overall score

Relative importance

Simplicity (not difficult or complex) Scalable

1. Assessing readiness for ART initiation even in the absence of treatment supporters

13 4.8 4.1 3.5 12.3 4.1

2. Generating weekly lists of eligible clients 10 4.9 4.2 3.9 13.1 4.4

3. Registering CD4 results in OpenMRS at the end of each week

13 4.8 4.5 4.4 13.6 4.5

4. Creation of specific child clinic days and have them synchronized with their parents’ ART initiation appointment days

10 4.8 4.2 3.8 12.8 4.3

5. Engaging volunteers to assist in ART documentation, especially ART register and patient ART charts

13 4.9 4.5 3.8 13.2 4.4

6. Identifying patients in pre-ART who are eligible to start ART monthly

11 4.7 4.2 3.6 12.5 4.2

7. Holding weekly audit meetings to identify and address documentation challenges that delay ART initiation

10 4.8 4.1 3.8 12.8 4.3

8. Continuous Medical Education (CME) sessions, case conferences and mentorship sessions on ART to improve staff knowledge

11 4.7 4.0 3.8 12.5 4.2

9. Task shifting – introduced nurse refills and nurse-requested CD4 tests

12 4.9 4.7 4.5 14.1 4.7

10. Phone calls made to remind ART eligible clients to come for ART counselling on the specified appointment dates

13 5.0 4.5 3.9 13.5 4.5

11. Engaging expert clients to counsel ART eligible clients before they are initiated on ART

12 4.7 4.7 4.2 13.5 4.5

12. Transfer-out of eligible ART patients to nearest health facilities so that ART initiation is done from there

9 4.5 4.3 3.7 12.5 4.2


Table 3: Rating of change ideas implemented to improve retention of HIV+ patients on ART for more than 12 months

SN Change idea


testing this change

Rating Criteria

Total score


Relative importance


1. Identifying a focal person to update ART register 10 5.0 4.5 4.5 14.0 4.7

2. Introduced a storage section specific for files of ART patients who miss their clinic appointments

6 4.2 3.4 3.2 10.7 3.6

3. Introduced a 2-month refill for stable patients 11 4.9 4.8 4.8 14.5 4.8

4. Health education to patients on the need for adherence to scheduled appointments

11 5.0 4.9 4.9 14.8 4.9

5. Having clinic phone numbers on display so that patients can communicate if they will miss their scheduled appointments

9 4.7 4.7 4.7 14.2 4.7

6. Clients form and others enroll in peer support groups, that reduce stigma

10 4.9 3.3 3.7 11.9 4.0

7. Formation of teams to support client follow-up 9 4.8 4.1 3.8 12.7 4.2

8. Holding special clinic days for targeted client groups like adolescents and FSWs

11 5.0 3.4 3.5 11.9 4.0

9. Expert clients in communities who inform facilities of deaths among fellow clients

6 4.8 2.8 3.1 10.7 3.6

10. Designated counsellors on medical wards who inform ART staff of ART clients admitted or have died

9 4.7 3.5 3.8 12.1 4.0

11. Holding inter-facility meetings for facilities to share information on patient transfers

11 5.0 3.7 4.1 12.8 4.3

12. CME sessions covering counselling for ART retention and use of counselling visual aids

11 5.0 4.4 4.6 14.0 4.7

13. Harmonized/ synchronized child and parent appointment dates

11 4.9 5.0 5.0 14.9 5.0

14. Updating appointment dates to match bill balances for clients

10 5.0 4.9 4.9 14.8 4.9


Table 4: Rating of change ideas implemented to improve the proportion of clients on ART receiving viral load tests

SN Change idea


testing this change

Rating Criteria

Total score


Relative importance


1. CME sessions on VL monitoring 12 5.0 4.3 4.8 14.1 4.7

2. Encouraging clients to demand for VL monitoring tests

11 4.9 4.6 4.7 14.2 4.7

3. Generating lists of clients due for VL testing, and have their files tracked/identified

9 4.8 4.5 4.6 13.9 4.6

4. Synchronized VL testing dates with ARV refill dates for eligible clients

11 5.0 4.7 4.8 14.4 4.8

5. Collection of VL samples throughout the day, as opposed to only mornings

10 5.0 4.6 4.7 14.3 4.8

6. Designating an individual to conduct phlebotomies on site

11 5.0 4.7 4.8 14.4 4.8

7. Prioritizing access for clients with clinical failure, and risk groups like pregnant mothers

6 4.5 4.5 4.3 13.3 4.4

8. Redistribution of viral load kits from lower facilities to high-volume facilities, to manage stock-outs

3 4.6 3.5 3.4 11.5 3.8

Change package for improving HIV care and ART services at high-volume hospitals in Uganda

Intended Use

Hospital administrators, heads of ART clinics and

front-line health workers taking care of pre-ART

and ART patients are the primary intended users

of this change package. Others like NGOs involved in

improving access, quality and safety of ART services,

district health officers supervising health facilities

and Ministry of Health officials working on strategies

to achieve the 90-90-90 goal will find the evidence-

based high impact changes described in the following

pages useful. It should be noted that hospital-based

improvement teams should not necessarily copy these

change ideas, rather, they should adapt them to suit their

circumstances and context challenges.

The next section of this change package provides a

detailed description of what changes led to improvement,

and how such improvement was derived. It is structured

into three sub-sections, corresponding with the three

improvement aims that the SUSTAIN project set out to

achieve in relation to HIV care and ART services. Each

sub-section outlines the QI change concept applied, the

problem being addressed, the change ideas tested, steps

followed in introducing each change idea and the evidence

that it led to improvement.


Figure 2: Proportion of HIV+ patients eligible for ART who were immediately started on ART

Per

cent

100

80

60

40

20

0

Improvement Aim 1: To improve the proportion of clients in HIV care who are enrolled on ART to 95% by September 2016 at 11 Regional Referral Hospitals and 1 General Hospital in Uganda.

Between 2013 and 2016, as illustrated in Figure 2,

there were significant improvements in the proportion of

eligible HIV+ patients successfully enrolled on treatment

at SUSTAIN supported hospitals. An improvement of

20%, within three years, can be attributed to the changes

introduced through SUSTAIN’s assistance.

68 69 70

87

2013 2014 2015 2016

Table 5: Specific changes introduced to improve ART initiation among HIV patients in care

Change concept

Specific problem being addressed

Change ideas tested Steps in introducing the change ideas

Evidence that the changes led to improvement

Scale of implementation

Easing the process of service delivery based on feedback from clients

Rigid and stringent expectations, that required eligible patients to come along with treatment supporters before ART initiation

Assessing readiness for ART initiation even in the absence of treatment supporters

• Emphasis was put on pre-ART counselling, to adequately prepare patients for ART

• Even in the absence of treatment supporters, counsellors assessed for understanding and comprehension of the different messages they were passing on to patients

• Counsellors also reviewed key messages from previous counselling sessions

• Only after counsellors were convinced that a patient is ready to start treatment, they were initiated on ART with or without a treatment supporter.

Within a year of implementing this change idea, Mubende RRH moved from initiating 10% to initiating 90% of eligible patients on ART. Lira RRH moved from 68% to 89% within 20 months.

12 hospitals tried out this change

Perform preparatory steps early

Delays in identifying and communicating which clients are eligible for ART initiation

Generating weekly lists of eligible clients

• The ART clinical team worked with the data team to identify, list and share those patients with low CD4 levels on a weekly basis, that constituted a list of patients eligible for starting ART

• Once identified, ART-initiation and ART-adherence counsellors would embark on preparing those specific patients for the ART journey

Fort Portal RRH tested this change and its ART initiation improved from 20% to 89% within 8 months.

10 hospitals tested this change

continued


Change concept





Standardize timelines for performing specific tasks

After CD4 tests had been conducted and results released, they would not be immediately entered into OpenMRS, an electronic medical records system, and this would delay identification of eligible patients.

Registering CD4 results in OpenMRS at the end of each week

• Once CD4 results were released by the lab team, the data team would work on having them entered into OpenMRS within the shortest time possible

• CME sessions were held with the data team on how CD4 results can be efficiently, accurately and consistently captured into OpenMRS

• One week was set as an internal target and deadline for updating patient records once their CD4 came from the lab

Lira RRH improved their ART initiation from 78% in October 2014 to 93% by January 2016.


Customize services to specific population groups

Parents complained about the need to return to the clinic on separate dates and have their children initiated on ART

Creation of specific child clinic days and have them synchronized with their parents’ ART initiation appointment days

• This change idea was generated during a QI meeting reviewing performance of pediatric HIV care

• It was decided that ART appointment dates be synchronized for both parents and their children, to minimize costs associated with multiple clinic visits

• During the pre-ART preparation process, parents were required to attend the necessary sessions with their children and to perform the required tasks with them.

Adherence to scheduled appointments improved for both adults and children in Jinja and Arua RRHs, and this contributed to improvements in ART initiation


Utilize alliances and cooperative relationships

Inconsistently documenting CD4 results in patients’ ART clinic charts, making it difficult to identify those eligible for ART initiation

Engaging volunteers to assist in ART documentation, especially ART register and patient ART charts

• Volunteers were trained by the clinic heads and the data team on how to identify CD4 figures from the lab results, and how to enter results of specific patients into OpenMRS

• Even after training, they were supervised by various clinic team members as they executed their tasks

• In addition to CD4 documentation, these volunteers also assisted the clinic team to update other fields in the pre-ART and ART registers and ease the documentation burden on the clinic staff

• This change required volunteers to work with clinic heads, the data team and the community linkage coordinators

Documentation of CD4 results in patient charts greatly improved across facilities that tested this change


Table 5: Specific changes introduced to improve ART initiation among HIV patients in care, continued

continued


Change concept





Change the order of process steps

Inconsistently documenting CD4 results in patients’ ART clinic charts, making it difficult to identify those eligible for ART initiation

Identifying patients in pre-ART who are eligible to start ART monthly

• Data team was tasked with generating a list of pre-ART patients eligible for ART initiation for the subsequent month

• The list was shared with the HIV clinic heads, ART counsellors, and community linkages coordinators

• On month end, this list would be reconciled with that of patients who have initiated ART during the month, and those who missed-out singled out

• List of patients who missed ART initiation would be shared with the community linkages teams for follow-up

Among facilities that tested this change, the number of eligible patients waiting for ART initiation gradually reduced.


Devote time to finding and removing bottlenecks

Holding weekly audit meetings to identify and address documentation challenges that delay ART initiation

• During monthly HIV clinic improvement meetings, participants suggested the reliance on data reviews to identify documentation challenges related to delays in ART initiation

• Instead of relying on monthly reviews, the team decided to conduct weekly audit meetings to review ART-related documentation and identify any gaps

• The data team, clinic staff and volunteers worked together to ensure patients’ records are accurate and consistent from the HIV care card, to the ART register and to the OpenMRS information system

Arua RRH tested this change and updating of CD4 results in patient files improved from 32% to 90% by August 2014


Provide training

Staff movements resulted in uneven knowledge levels among HIV clinic staff

CME sessions, case conferences and mentorship sessions on ART to improve staff knowledge

• Clinic heads scheduled CME sessions to be held on a weekly basis, during HIV clinic meetings

• Subject matter experts were identified and tasked with preparing for these talks

• Topics (and identified experts) included criteria for ART initiation, CD4 testing, adherence counselling, symptoms and treatment for opportunistic infections and TB/HIV care

Knowledge of ART care became wide-spread and evenly distributed across all staff in the HIV clinic


Use substitution

Frequent absences of medical officers often stalled the continuous monitoring of ART patients

Task shifting– introduced nurse refills and nurse-requested CD4 tests

• HIV clinic teams empowered nurses to prescribe ART re-fills and authorize the request for CD4 tests, a deviation of the norm of leaving such tasks to doctors alone

• Nurses had been trained on the different ART regimes, their side-effects and efficacy levels. They had also been trained in CD4 monitoring and the interpretation of changes in patients’ CD4 counts; since most health facilities have high numbers of nurses, and not of doctors, nurses’ availability ensured these functions were often conducted without significant delays

• The process of assigning some tasks to nurses also freed-up doctors’ time so they could focus on the more complicated cases in ART care

Patients’ experiences during ART clinic days improved, as stable patients did not have to wait to see medical officers



continued


Change concept





Use reminders

Failure for patients to report to the health facilities on scheduled clinic days, sometimes due to forgetfulness

Phone calls made to remind ART eligible clients to come for ART counselling on the specified appointment dates

• Patients eligible for ART could not be initiated on treatment until after they had undergone the necessary ART counselling sessions

• Patients who would fail to turn up for the scheduled counselling sessions would be followed up by phone calls reminding them of their missed appointments

• In many other cases, patients with scheduled counselling sessions would be called prior to the due dates and be reminded of the need to adhere to their appointments

Turn up for adherence counselling sessions greatly improved among the facilities that tested this change, and timely ART initiation subsequently improved


Utilize alliances with existing beneficiaries

Patients expressed disbelief and dissatisfaction with ART messages from health workers

Engaging expert clients to counsel ART eligible clients before they are initiated on ART

• The clinic team identified ART patients who had been in care for a long time, were stable and had registered good clinical outcomes

• The clinic team was trained in adherence counselling, and guided on how they could use their experiences to encourage and support others

• During clinic days, they provided ART counseling to newly eligible patients and emphasized adherence both to treatment and to scheduled clinic appointments

Patients identified better with expert clients and were more willing to initiate ART after counselling sessions with the expert clients


Move services and clients closer to each other

Patients were reluctant to initiate ART from a facility that they felt was not conducive for long term HIV care and treatment

Transfer-out of eligible ART patients to nearest health facilities so that ART initiation is done from there

• During ART adherence counseling, patients were asked whether it was easy and affordable (cost-wise) to access ARVs from that health facility

• Those patients who disagreed proceeded to being initiated on ART, and those who agreed were presented with options of initiating from elsewhere

• Patients who desired getting their ARVs from facilities nearer to their homes were encouraged to do that, and issued with transfer out forms and contacts of staff in the new facility

Health facilities that tested this change observed reductions in loss-to-follow-up of ART patients soon after they are started on treatment

Nine hospitals tested this change



Figure 3: Percentage of HIV clients alive and on treatment 12 months after initiating ART

Per

cent

100

80

60

40

20

0

81 8085 83

2013 2014 2015 20162011 2012

8085

Improvement Aim 2: Improve the proportion of HIV clients on ART that are alive and well 12 months after initiating treatment

Figure 3 demonstrates the overall stagnation in 12-month

retention of patients on ART. In 2016, retention on ART

was at 85% amongst hospitals supported by SUSTAIN.

Table 6: Specific changes introduced to improve retention of ART clients in care

Change concept





Use a Coordinator

Facilities had challenges tracking which patients were in care at any given time

Identifying a focal person to update ART register

• During monthly QI meeting, the HIV clinic teams agreed on the importance of using the ART register and keeping it updated as it helps facilities capture the number and status of patients in care

• A focal person was identified from among the clinic team, and tasked with coordinating and supervising update of the ART register

• Specific fields in the ART register that require special focus were the patients’ telephone contact and their recent CD4 results, as these are areas that had been chronically problematic

• The identified focal person worked closely with volunteers and the data team, to ensure specific tasks were completed.

Fort portal RRH tested this change and improved ART retention from 40% in December 2012 to 93% in September 2016. Other facilities that tested this change could easily and accurately determine the number of patients who were alive and on treatment at any given time.


Re-align processes so that activities that follow each other are close together

Facilities were not able to identify and trace ART files of patients who had missed clinic appointments

Introduced a storage section specific for files of ART patients who miss their clinic appointments

• ART files for patients expected on a clinic day were retrieved a day before and availed to the clinic team

• At the end of the clinic day, files of patients who missed appointments were collected and kept in a specifically designated storage area

• When these patients eventually came to the clinic, it was easy to identify and retrieve their files to receive care

Documentation in the ART files of patients who had missed appointments was possible, and easier, confirming their retention in care

Six hospitals tested this change

continued


Change concept





Listen to clients and be receptive to their requests

Patients were uncomfortable with the costs associated with monthly clinic visits to pick medicines, and some missed clinic visits because of costs

Introduced a 2-month refill for stable patients

• The clinical team worked with the data team and adherence counsellors to identify stable patients who had been in care for over 12 months

• If patients had demonstrated good ART adherence during that period, it was decided that they are offered two-months’ worth of ARVs

• They were still required to report to the health facilities for re-fills and clinical assessments, but did not have to make the monthly trips

Lira RRH improved its adult ART retention from 55% to 74% by June 2016.


Provide clients with information

ART patients were consistently missing their scheduled appointments, affecting their retention in care

Health education to patients on the need for adherence to scheduled appointments

• HIV clinic head tasked adherence counsellors to give sessions on sticking to scheduled appointments for the ART clinic

• On each clinic day, group counselling sessions were conducted that emphasized the benefits of not only ART adherence but also appointment adherence

• Hindrances to appointment keeping were identified, discussed and addressed during the group counselling sessions

Adherence to scheduled appointments improved among facilities that tested this change


Patients often missed their appointment dates, and fail to alert the clinic staff

Having clinic phone numbers on display so that patients can communicate if they will miss their scheduled appointments

• Health workers decided which phone numbers to share with patients, and had them written in clearly visible digits on manila papers, and posted them around the triage area

• During health education sessions, patients were encouraged to contact clinic staff using the same numbers and alert them whenever they were to miss their appointments

• Patients could call the same numbers to inform clinic staff of any changes in their condition, even without coming into the health facilities

Adherence to treatment in Arua RRH improved from 62-82%. In some health facilities, patients started calling health workers inquiring if they could report for refills earlier than had been scheduled


Support clients to develop alliances and cooperative relationships

Stigma forced some patients to stop coming to health facilities for care

Clients formed peer support groups to address stigma

• Patients formed peer groups to provide support and share knowledge amongst themselves

• They encouraged each other to stay strong even in the face of stigma, and to always adhere to their clinic appointments

• They also shared tips on how to disclose their HIV status to close family members, and how to encourage more people to test

Patients developed stronger bonds amongst themselves, and even supported themselves in starting up income generating activities. In Jinja RRH, retention improved from 62% to 98%.


Table 6: Specific changes introduced to improve retention of ART clients in care, continued

continued


Change concept





Use coordinating teams

Even though hospitals would effectively identify clients who were no longer in care, only occasionally would they follow them up

Formation of teams to support client follow-up

• Hospitals formed teams specifically for following up clients who’re missing scheduled appointments

• On a weekly basis, the data and clinical teams identified these clients, and handed over their names and addresses to the follow-up team

• Hospitals received funding from SUSTAIN and other IPs to facilitate patient follow-up

• Various follow-up approaches were used: phone calls and/or home visits

Loss to follow-up greatly reduced in hospitals that tested this change, as more clients were encouraged to get back into care



Partly due to stigma, certain population groups easily dropped out of care even after they were enrolled

Holding special clinic days for targeted client groups like adolescents and commercial sex workers

• QI teams advised HIV clinic teams to treat adolescents, commercial sex workers and men-who-have-sex-with-men (MSMs) as special population groups

• Clinic teams then set up separate clinic days for each of these groups, and passed on the information during health education talks

• Since these clients are relatively fewer in number, only 1-2 health workers were tasked with seeing the key-population clients on these special clinic days

Retention on ART of key populations greatly improved


Develop alliances and cooperative relationships with expert clients

If clients died, HIV clinic teams would often consider them as lost-to-follow-up

Utilize expert clients in communities to inform facilities of deaths among fellow clients

• Expert clients were identified from each village in the catchment area, from among patients in care.

• Since expert clients are already trusted by their clients, the clinic teams furnished them with names and addresses of their colleagues in their communities

• These expert clients were asked to act as community informers, checking on their colleagues receiving care from the same facility, and feeding back that information to the clinic team

• In the unfortunate event of death of one of their peers, the expert clients would quickly inform the HIV clinic team, so that the pre-ART/ART registers could be updated and the HIV care card withdrawn

• Such community informers would also provide information on migratory clients, who might have emigrated from their communities

Over-time, HIV clinic teams developed more reliable data of patients in care, and could accurately weed out the dead



continued


Change concept





Establish sources of key information and link it to stakeholders

For clients who died while admitted in the medical wards, HIV clinic teams would not be informed and still consider them as lost-to-follow-up

Designated counsellors on medical wards who inform ART staff of ART clients that have been admitted or have died

• QI teams within the HIV clinic liaised with QI teams at the medical wards of the same hospitals to alert them if any of their clients were admitted in their wards, and had died

• To facilitate the identification of clients and coordination of information between the HIV teams and the wards, the HIV clinic team designated counsellors to be stationed at the medical wards to perform this function

• QI teams used an admissions book stationed in the HIV clinic, in which ART clients found in the medical wards would be documented

HIV clients who died while admitted were easily identified and information was conveyed to the HIV clinic data and clinical teams


Sharing of information between facilities

For patients who transfer-out, their health care information wouldn’t be transferred to the recipient facility

Holding inter-facility meetings for facilities to share information on patient transfers

• Once the HIV clinic team ascertains which facility a client has transferred to, they would contact their clinic team to have their file (HIV care card) availed to them

• Periodically, HIV clinic teams from different facilities (in the same district) would get together to share information on patient transfers

• These inter-facility transfers were coordinated by the HIV Care Coordinator in the District Health Office

• During health education sessions, clients were always told to request for formal transfer-out whenever they decided to seek care from another facility

Sharing of client’s records improved among facilities, and un-aided self-transfers were greatly reduced.


Provide training

Patients would get tired of taking ARVs, and wouldn’t come back for refills

CME sessions covering counselling for ART retention and use of counselling visual aids

• Adherence counselling was designed to address both ARV adherence and appointment adherence

• Adherence counsellors were trained and encouraged to emphasize retention in care as the best indicator for client’s adherence

• Counsellors used visual job aids to tell clients the consequences of non-adherence to scheduled appointments: effects included emergence of opportunistic infections and death

Adherence to ARVs increased in facilities that tested this change



Parents often failed to honor their children’s clinic appointments, even when they could honor theirs

Synchronized child and parent appointment dates

• QI teams identified the costs associated with multiple clinic visits as one of the reasons some patients were not coming back for refills. Parent/child pairs were some of the groups most affected.

• Facilities started synchronizing appointment dates for children and their parents, by giving them the same amounts of drugs

• On the scheduled appointment, the parent/child pair would make a single, monthly trip thereby saving them transport costs and time

Retention of children in ART greatly improved. In Lira RRH, retention of children on ART increased from 57% to 82% after testing this change.



continued



Change concept





Synchronize and minimize duplication

Clients would accumulate pill balances carried forward from previous refills, and had no idea what to do with them

Updating appointment dates to match pill balances for clients

• During adherence assessment, clients were asked to mention their pill balances

• Before new pills (refills) were issued, the equivalent of the remaining pills was deducted from the new issuance

• Counting pill balances ensured clients were only getting refills that they needed for that period

The amount of drugs that the clients had and carried forward greatly reduced


Figure 4: Proportion of clients due for viral load testing in a month that have accessed it

Per

cent

100

80

60

40

20

0

40.5

18.1

31.9

2015 20162014

Improvement aim 3: To improve the proportion of clients on ART receiving viral load tests

Because of SUSTAIN’s support, the proportion of clients

due for viral load testing who received the service more

than doubled between 2014 and 2016, as illustrated

in Figure 4. Improvement is attributable to hospitals

introducing several changes to improve access to viral

load testing. Details of these changes are outlined in

Table 7.

Table 7: Specific change ideas to improve access to viral load testing

Change concept





Provide training

There were significant knowledge gaps amongst staff on viral-load monitoring

CME sessions on viral load monitoring

• Clinicians, nurses, lab staff and data staff were trained in the need and process of viral load testing and monitoring

• Supported by SUSTAIN, trainings covered the frequency of viral load testing, the forms used in requesting a test, sample collection procedures and interpretation of results.

• Periodically, these capacity building sessions were repeated during CPD sessions

Soroti RRH had 76% of their ART clients receiving viral load tests by January 2016


continued


Change concept





Listen to customers

Due to data gaps, hospitals had limited capability of identifying which clients were due for viral load testing

Encouraging clients to demand for viral load monitoring tests

• During health education sessions, clients were asked to always remind health workers to check their eligibility for viral load testing

• Members of the triaging team were also tasked with checking clients’ files and identify those eligible for viral load testing in which those found eligible would be guided on the procedure for obtaining the tests

In Fort Portal RRH, viral load testing improved from 58% to 71% by June 2016.


Rearrange the order of steps in a process

Generating lists of clients due for VL testing, and have their files tracked/identified

• Based on clinic records in OpenMRS, clinic teams could determine which clients were due for viral load testing

• Prior to their subsequent appointment dates, their files would be retrieved and triage team alerted that those clients needed to have their viral load testing done

• On arrival for their scheduled appointment, such patients would be guided to the lab and have the blood samples taken

Since files were retrieved in advance, clients would efficiently go through the normal refill visit without any delays, even when they were combined with viral load testing.


Synchronize and minimize duplication

Client frustration due to un-harmonized appointment dates between viral load testing dates and ARV refill dates

Synchronized viral load testing dates with ARV refill dates for eligible clients

• Using information provided by the data team, the clinic team could tell when a client’s viral load testing is due. They then scheduled an ARV refill date to coincide with that date.

• In a single visit, clients could get both their viral load tests done and their ARV refills

Viral load testing increased in facilities that tested this change


Provide services whenever clients need them

Clients would miss out on viral load testing if they reported past the allocated time

Collection of viral load samples throughout the day, as opposed to only mornings

• HIV clinic teams identified focal persons responsible for performing viral load tests for clients due for a test, who would be available throughout the day, and was allocated secure space to use as the bleeding room

• Whenever clients eligible for viral load testing were identified, at whichever time of day, they were directed to the bleeding room from where the VL focal person would be waiting

In Lira RRH, where this change was tested, VL testing improved from 18% to 77% by July 2016


Use a Coordinator

Several clients had missed out on VL testing due to logistical challenges (stationary and test kits) and absence of competent staff

Designating an individual to follow up clients and to conduct phlebotomies on site

• Hospitals identified focal persons (preferably phlebotomists) to identify and follow-up with clients who had missed their VL tests

• The focal person followed up clients through phone calls and scheduled appointments for when they could have their VL tests done

• The focal person also ensured the test kits and VL request forms are available, often by acquiring them from lower health facilities or through CPHL requisitions

Kabale RRH had 852 eligible clients received VL tests between April and June 2016, and Hoima had 876 by June 2016.


Table 7: Specific change ideas to improve access to viral load testing, continued

continued


Change concept





Prioritize services to specific population groups

Limitations in resources dictated that only a few clients could have their VL tested

Prioritizing access VL testing for clients with clinical failure, and risk groups like pregnant mothers

• The lab staff worked with the data team to identify those clients with low CD4 counts, by going through their clinical files and tagging them with a VL test request that were then recommended to clinicians as the priority clients to receive VL tests, as resources were limited

• At their subsequent clinic visits, these identified clients would be informed that they were due for VL testing and guided on how to get the tests done

Gulu RRH tried this change to clear its backlog of clients, and by June 2016 had done 1,120 viral load tests


Match the amount of supplies to the need

Persistent stock-outs of viral load kits hindered many facilities from conducting VL tests

Redistribution of viral load kits from lower facilities to high-volume facilities, to manage stock-outs

• Whenever the HIV clinic teams were facing shortages of viral load kits, they would inform their district HIV focal person

• Based on understanding of the landscape of HIV care and treatment in the district, this focal person would have information on which facilities might have excess/under-utilized viral load kits

• Facilities teams then work with the district teams to redistribute kits from less-consuming facilities to large consuming facilities

• During subsequent requisition cycles, the district focal person works with all facilities to ascertain accuracy in forecasting demand for viral load kits

By redistributing viral load kits from where they are not used to where they are needed, eligible clients receive services in a timely manner.

Three hospitals tested this change

Table 7: Specific change ideas to improve access to viral load testing, continued


As has been documented in various health system

strengthening initiatives, improvement teams faced

significant challenges while testing the different

change ideas aimed at improving HIV care and treatment

at the supported health facilities. Key among them

included:

n Increased work-load: Health workers were required

to hold more meetings, document more accurately

and spend substantial amounts of time analyzing

performance data. These additional tasks were viewed

as increased work load, as nurses, clinicians and other

staff were required to dedicate additional time to the

HIV/ART clinic to perform these roles. Many health

workers felt that these additional tasks should come

with additional pay, to compensate the amount of time

dedicated.

n Patient complaints: Some of the tested changes were

associated with unpleasant experiences for patients,

who in-turn viewed the quality of care as unfavorable.

Examples of these changes included longer waiting

times for patients, as health workers increased the

time allocated to counselling new patients prior to

ART initiation. The new patients benefitted from better

preparation before initiating ART, but other patients

complained that they had to wait longer for their review

and refills. Other complaints came from patients who

had to return to health facilities within a week to receive

their CD4 results, and potentially initiate ART. Although

the QI team wanted the ART eligible patients to be

able to initiate treatment as soon as their results were

released, the patients complained that returning to a

health facility within a week of one visit resulted in a

significant financial burden.

n To shortages in human resources, health workers

often introduced volunteers, interns and support staff

to assist (or take lead) in the implementation of various

change ideas. In some cases, unfortunately, these

volunteers failed to respect set boundaries and would

assume the roles of health workers. This challenge

mainly manifested during triaging of patients, ART

counselling and allocation of clinic-return dates. It

created a challenge of quality control and ownership

of responsibilities during the execution of the clinical

roles.

Key Challenges


To get the best benefit from the change ideas

proposed in this document, health facilities

should establish and cultivate an environment that

embraces change to nurture improvements. The following

ideas can help QI teams in getting started:

n Improve documentation — Existing national

documentation and data monitoring tools need to be

accurately and consistently used. It is through these

tools that teams will be able to determine whether their

performance is stagnating or improving, both before

and after introducing these changes.

n Establish team work — For any improvement work to

yield positive results, health workers must collaborate

and view themselves as members of a team

responsible for the different steps in the processes of

providing health services.

n Analyze the entire process of care, and prioritize —

After analyzing their processes of care, and identifying

existing gaps, health workers should prioritize which

challenges need to be and can be tackled first and

which ones can wait. Addressing one challenge at

a time (while introducing a few changes at a time)

will enable health workers to systematically monitor

the effectiveness of each change in addressing a

challenge, and the effect of a process gap on the

overall service delivery.

Moving Forward

n Constantly communicate with your patients —

Improvements are designed to primarily benefit

patients. Health workers should constantly seek

feedback from patients on the quality of service

they are provided, and whether the changes being

implemented are benefitting them as well.

In addition to health facility QI teams, other stakeholders

have differing roles (as indicated in the table below)

in the spread of these change ideas and further

institutionalization of the culture of continuous quality

improvement:

Ministry of Health

• Ensure the required tools, standard operating procedures and other resources are available throughout all levels of the health system

• Support coordination, capacity building, supportive supervision, resource mobilization as they relate to scale-up of QI interventions

District Health Officials

• Supportive supervision, coaching and mentorship of health facilities attempting QI projects

Development Partners

• Provide technical support and avail resources to bridge funding gaps within the MOH

USAID | SUSTAIN

STRENGTHENING UGANDA’S SYSTEMS

FOR TREATING AIDS NATIONALLY

Plot 7, Ntinda View Crescent

Naguru, Kampala, Uganda

Tel: +256 (0) 312-202-046

Fax: +256 (0) 414-287-614

www.sustainuganda.org

University Research Co., LLC

5404 Wisconsin Avenue, Suite 800

Chevy Chase, MD 20815

Tel: (301) 654-8338

Fax: (301) 941-8427

www.urc-chs.com

strengthening uganda’s systems for treating aids ... · patients for art eligibility, ensure...

Documents