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

2. Hello! I am xxx I am here because I love to give presentations.
You can find me at:
@username

3. SITE SUPERVISION

4. Types of Site Supervision
Supportive supervision visits
Continuous quality improvement visits

5. 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

6. 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

7. 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

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

9. 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

10. CQI BACKGROUND

11. 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. 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

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

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

15. 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

16. 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

17. 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

18. CONTINOUOUS QUALITY IMPROVEMENT

19. 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

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

21. 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

22. 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.

23. FHI QA and QI Guiding Principles

24. 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.

25. CQI METHODOLOGY

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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.

36. SUPPORTIVE SUPERVISION & CQI TOOLS

37. 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

38. 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

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

40. 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

41. ACTION PLANS

42. 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 ) 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.”

43. 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

44. 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

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

46. 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.

47. Questions? Comments?

48. Thank You!