1. Assessing & Improving Quality of Care Newly Developed Quality of Care Tools President’s Emergency Plan for AIDS Relief Track 1.0 ART Program Meeting Seema Meloni, PhD, MPH Assistant Country Director, Harvard PEPFAR Nigeria 25 September 2007

2. Harvard PEPFAR Nigeria Two Tools for Improving Care Quality Improvement Treatment Response Utility: “Snapshot” of patient Quality Assessment Site Assessment Database

3. Quality Improvement

4. Harvard PEPFAR Nigeria Overview: Database System Electronic capture of patient data from program inception Data captured for Adult, Pediatric, and PMTCT program areas Pre- assessment Entry ARV naïve ARV experienced ART eligible ART ineligible Palliative Care Visit Lab Pharmacy ART eligible Discontinue ToxicityFailure VCT

5. Harvard PEPFAR Nigeria Paper records Daily entry at program sites; Merged & cleaned weekly Uploaded to Server Paper record placed in patient chart Best clinical management of patients Reports Projections Program Evaluations (QA) Downloaded in Boston; merged and reviewed Treatment Response Utility

6. Harvard PEPFAR Nigeria Treatment Response Utility Goal: Improve treatment process by providing clinicians quick and easy access to patients’ treatment- related data Patient ID #

7. Quality Assessment

8. Harvard PEPFAR Nigeria Evolution of Internal QA Program JSI Quality Assessments at 3 sites Informal quality improvement efforts through ongoing monitoring of site progress and visits from clinical officers Internal development of a quality assessment protocol Technical assistance on indicator selection provided by JSI Full assessment: 3 sites (different from JSI QA) Follow-up assessment on 1 site previously assessed by JSI

9. Harvard PEPFAR Nigeria Site Assessment Goals Assess quality of care provided to HIV/AIDS patients Identify strengths and weaknesses in clinical processes/systems Evaluate health outcomes of patients as related to clinical processes Promote accountability for patient care Facilitate the process of joint problem identification and solving

10. Harvard PEPFAR Nigeria Site Assessment Indicators Informed consent coverage CTX coverage TB screening coverage Lab data % Charts missing values Toxicity % patients with panic values % patients with appropriate clinical response(s) CD4 and Viral Load % patients with values at baseline, 3, 6, and 12 months % patients with CD4>200 and/or suppressing viral load at 6 and 12 months Treatment failure % patients in failure at 6 and 12 months % patients with appropriate clinical response(s)

11. Harvard PEPFAR Nigeria Site Assessment Database Basic procedure: Random sample of patient IDs selected from master databases. SA database preloaded with data from master Entry, Lab, Pharmacy, and Visit databases Database taken to site; data in charts compared to data loaded into SA database In addition, evaluate a few additional indicators to further evaluate quality of patient care

12. Harvard PEPFAR Nigeria Chart Review & Data Entry Click through tabs to access data for various indicators Data in unshaded fields are pulled from master files in Boston Fields shaded in yellow are meant for SA team to enter notes Pulled from Tx Response Utility

13. Harvard PEPFAR Nigeria Chart Review & Data Entry Electronic tool makes it easy for on- site analyses Jump to analysis screen and “find” all records that address given indicator

14. Harvard PEPFAR Nigeria Innovative Additions Red flags indicating possible virologic failureCalculator for 6- and 12-month CD4 & VL Layout that provides data summary

15. Harvard PEPFAR Nigeria Tools Have Improved Quality & Efficiency Treatment Response Utility Minimizes time clinician must spend reviewing patient charts Provides evaluation of adherence and treatment failures Will be adapted and used for transfer patients - allows for continuity of care Site Assessment Database Has sped up process of site assessments and allows us to evaluate our program more in-depth Allows for detailed debriefing the day after chart review is complete Can be used by sites for their own QA/QI initiatives

16. Thank you