TRACE INITIATIVE: Site Supervision and Continuous Quality Improvement (CQI)

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SITE SUPERVISION

Types of Site Supervision Supportive supervision visits Continuous quality improvement visits

Supportive Supervision Objectives Ensure the quality of data and specimens Observe and compare practices with protocols Provide feedback on observations Provide guidelines or technical updates Use data to monitor progress Problem-solve as a team

Supportive Supervision Activities At each supervisory visit, the Officers will: Complete a brief electronic form, which abstracts data from the Recent Infection Surveillance Register Mentor HTS providers on recency testing and related HTS activities Monitor testing supplies (i.e. test kits, registers) Mentor HTS providers on recordkeeping and data quality Site supervisors will visit each site at least 1 time per week

Continuous Quality Improvement Objectives Understand level of quality Identify problems and root causes Develop corrective actions with relevant stakeholders Monitor problem-prone aspects Frequently measure changes in quality outcomes and performance

Continuous Quality Improvement Activities QI visits conducted at least once per month QI checklists To identify problems/possible solutions Feedback and coaching Monitor impact

Stakeholders’ Roles and Responsibilities MOH Owns data, provides technical oversight, provides staff for data collection and testing, and disseminates key findings CDC and USAID Provides technical support in design, implementation, analysis and use of findings Health facilities Specimen collection and transport Implementing partners and TA Support the roll-out and provides TA in implementation Laboratories Specimen receipt, testing, and return of results

CQI BACKGROUND

Definitions Quality Assurance (QA) is a periodic formal assessment to assure and measure the extent that service delivery sites meet minimum standards. Continuous Quality Improvement (CQI) is an ongoing, structured process, carried out by site- level staff to identify problems in quality care delivery, take remedial actions to achieve improvement, and carry follow-up monitoring to ensure no new problems arise and corrective steps have been effective.

12 Components of M&E Systems World Bank/MERG definition of 12 components of M&E System – different way of depicting the same thing - a functional systems need to be able to collect, manage, report and use high quality data. Where does QI fit in? Into a lot of components – especially data dissemination and use and supervision and data auditing Source: World Bank/GAMET

Integrated Cycle for Program Planning 1. Assessment 2. Strategic Planning 3. Design 4. Implementation/ Monitoring 5. Evaluation 6. Reporting/ Sharing Findings

CQI as Part of Planning Performance Do Study Act Source: Turning Point Performance Management Collaborative, From Silos to Systems: Using Performance Management to Improve the Public’s Health , March 2003.

To Carry Out a CQI Process, “Plan-Do-Study-Act” Plan Plan changes aimed at improvement, matched to root causes Do Carry out changes; try first on small scale Study See if you get the desired results Act Make changes based on what you learned; spread success Plan Do Study Act PDSA is the basic structure for most CQI processes

Barriers to Using Data for Program Decision-Making Availability of data Quality of available data Relevance to the population of interest Relevance of data to planning tasks at hand Manner in which data are presented Organizational problems that affect the decision making process

Using Data to Make Program Decisions Easily Step 1 Identify the problem or question you want answered Step 2 What M&E data is needed to answer the question? Step 3 Analyze / examine the data Step 4 Develop a program improvement plan

CONTINOUOUS QUALITY IMPROVEMENT

M&E and CQI M&E = Use of data from multiple sources to support evidence-based decision-making In order to achieve Continuous Quality Improvement of service performance Areas of Focus Stakeholders Collaboration Systems Change Measurement

Fundamental concept of improvement: “Every system is perfectly designed to achieve exactly the results it achieves”

What is Continuous Quality Improvement (CQI)? Principles of improvement: Understanding work in terms of processes and systems Developing solutions by teams of providers and patients Focusing on patient needs Testing and measuring effects of changes Peer learning Same principles of improvement as DQI – ultimately principles are the same thought tools and methods may differ. That’s because the approach to quality improvement is the same whether dealing with data or quality of service delivery issues. Source: HealthQual International

What is Continuous Quality Improvement (CQI)? CQI is… an ongoing, structured process; a process involving the identification of service delivery issues, and the implementation of activities aimed at improving quality care delivery and eliminating the challenges identified; and carried out by site-level staff to identify problems, take remedial actions, and carry follow-up monitoring.

FHI QA and QI Guiding Principles

Why is CQI important? CQI aims to: understand the current level of quality of care; identify problems or gaps between actual quality and expected quality for that setting; introduce corrective actions into the care system; monitor high-risk, high-volume, or problem- prone aspects of health care; and frequently measure the effect of those changes on health outcomes and system performance.

CQI METHODOLOGY

QA = Root Cause Analysis QA is a periodic formal assessment to assure and to measure the extent that service delivery sites meet minimum standards.

Overview of QA Methodologies Site and agency level assessments (i.e. QA, quarterly data completeness checks, routine validations, annual audits) Participatory method for root cause analysis and corrective action activities

PLAN Assessment/ indicator selection/ Action Plan Development DO Implement Action Plan as designed STUDY Monitor implementation, adjust as needed; evaluate change impact ACT Either feel confident in data or repeat cycle

QA Tools Affinity Diagram Flow Chart Cause and Effect Prioritization Pareto Chart Check Sheet Histogram Scatter Diagram People Centric / Qualitative (program development opportunities) Data Centric / Quantitative (program implementation/ monitoring opportunities) Double check source Source: CDC 2012

QA Tools: Cause and Effect Diagram (Fishbone) Test Location Client Don’t see benefit Inconvenient Don’t Want Test Too Public Fearful Poor HIV Testing Not Client Centered Not Respectful Not Offered Poor Experience Counseling Staff Source: CDC 2012

QA Tools: Flowchart Use to check and clarify how processes work Helps to identify breakdowns and bottlenecks Examines relationships among process steps in systems End Start Process Step Decision No Yes Source: CDC 2012

Brainstorm all possible Root Causes of low quality of service delivery 5/27/2019 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] Brainstorm all possible Root Causes of low quality of service delivery Percentage of counselors adhering to protocol = 55% Minimal training on recency testing procedures Availability of printed forms Low motivation of staff to provide services Lack of on-site supervision on adherence to protocol and guidelines

CQI = Action Plan and Follow-Up Measurement CQI is an ongoing, structured process, carried out by site-level staff to identify problems in quality care delivery and then take remedial actions to achieve improvement and carry follow-up monitoring to ensure no new problems arise and corrective steps have been effective.

Overview of CQI Methodologies Intervention occurs primarily at the site level Interventions should be simple, measurable, time constrained and able to complete with available resources Site level CQI needs regular monitoring and TA from partners and/or MOH Continuous cycle that requires ongoing assessment, intervention, monitoring Participatory site-level QI Plan Do Study Act (PDSA) Cycles

CQI Methodologies Continuous quality improvement (CQI) is the systematic process of identifying, describing, and analyzing strengths and problems and then testing, implementing, learning from, and revising solutions.1 More simply, one can describe CQI as an ongoing cycle of collecting data and using it to make decisions to gradually improve program processes. This figure shows this basic process.

SUPPORTIVE SUPERVISION & CQI TOOLS

Supportive Supervision and Quality Improvement Tools Job aids, SOPs, protocols (standards) CQI Supervision Checklists Summary Data Forms and Registers Action Plans CQI Prioritization Matrix PDSA Worksheet

Electronic Tablets Checklists Supervision Visit Log Illustrative Examples of Tools Electronic Tablets Ex: ODK Form to capture Recent Infection Surveillance Register Checklists Ex: Supply checklist, site-level CQI checklist Supervision Visit Log

[Country Team to Insert Group Activity on How to Use CQI Checklist]

Illustrative Examples of CQI Indicators Percentage of persons aged ≥15 years newly diagnosed with HIV-1 infection who have a test for recent infection result of recent infection during the reporting period (MER Indicator - HTS_RECENT) Percentage of persons eligible offered recency testing of those eligible for recency testing Percentage of persons incorrectly enrolled (aged <15 years, did not consent, etc.) Quality of counseling - Percentage of counselors adhering to protocol of those assessed through direct observations Return of Results: Usage of counseling script for return of results by counselors Return of Results - Review of rejection codes to ensure quality of specimens for viral load testing Turnaround time for return of results

ACTION PLANS

How to develop a CQI “Action Plan” Using the Action Plan Template, record the indicator to improve; the root cause of poor service quality; and activities to help correct the cause of poor performance. To select the root cause for corrective action, review the Fish Bone Map. Star causes that have 1.) High impact on service quality and 2.) Fall under the influence of the health facility team. Avoid causes that are outside of the control of the group. Be as specific as possible , “delay in turnaround time for results.”

How to develop a CQI “Action Plan” Define intervention activities that can correct the root causes of poor quality service delivery. Construct activities with SMART characteristics: Specific: Identify who, what, when, where and how activity will be carried out Measurable: Define the intensity, frequency, and duration of activity Appropriate: Select relevant intervention activities that are able to create change and related to the specific issue Realistic: Select intervention activities that are achievable within the scopes of the project/program. Time-bound: Select an activity that can be completed in the cycle timeframe

Example Action Plan Indicator Performance Gap Root Causes Interventions to Address Gaps Timeline Person Responsible HTS_RECENT Under testing of eligible persons Low motivation among staff to provide services Increase recognition of good performance during review meetings, with certificates and incentive gifts to star performing sites July - December 2019 QI Supervisors & MOH Lack of on-site supervision on adherence to protocol and guidelines QI supervisors review service providers activities on a quarterly basis during supervision sessions QI Supervisors & MOH, Service Providers Minimal training on testing procedures QI supervisors will provide onsite training for 1 day, twice a year. MOH will provide 5 day Training-of-Trainers. District Teams

Group Activity: Action Plans Indicator Performance Gap Root Causes Interventions to Address Gaps Timeline Person Responsible

CQI Recap Recap: In its most simple form, CQI collects data at baseline, followed by an action plan to develop interventions with the expectation that quality will indeed improve with close monitoring and dedicated action. Subsequent follow-up visits will then be used to measure and assess any actual quality improvements. The CQI process is, by definition, continuous, and each subsequent visit seeks to improve overall quality of recent infection testing services.

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