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 Quality 2004-2006 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 935 randomly 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 Women62% Age - >3560% Median CD4137 (114 – 178) On ART at program entry 4 – 26%

9. CITanzaniaSouth AfricaZambia Last seen > 6 months ago (all pts) 12%2% 7% ART patients Seen in review period 100%98% 96% Missed visit13%16%8%26% Outreach if missed visit* 0% 22%10% Adherence to care and missed visits *documented in chart

10. ART and Response CITanzania South AfricaZambia Started on ART if eligible 57%87%93% Interruption7%10%8%24% Response if on ART >6 months*96%90%95%89% CD4 change (median)**124 117153 Last CD4 >200100% 93% * 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