QI COLLABORATIVE OVERVIEW

To improve the continuum of HIV services, from HIV testing to linkage to care, treatment and support for PLHIV in the Dnipropetrovsk region, a Quality Improvement Collaborative was established in September 2015.

On February 2, 2016, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Dnipropetrovsk Regional Healthcare Department. Between December 2015 and January 2016, 37 local QI teams were created around the existing ART sites. In December 2016, another three ART sites have joined the Collaborative so as of January 1, 2017, there are 39 QI sites in the region (One was excluded lately).

Each QI team is comprised of the ART site staff, specialty physicians (STI, narcology and OB/GYN), their nurses, primary healthcare practitioners, and social workers of the regional NGOs.

Regional QI Implementation Group (RIG): Regional Coordinator – Hanna Lopatenko, QI Mentors – Maria Hudova, Iryna Sodel, Liliana Kvasha, Iryna Kozina, Data Quality Mentors – Nadiya Marchenko, Svitlana Barhan.
 

QI Coach QI Coach
Dnipropetrovsk Regional AIDS Center  Iryna Chukhalova
Kryvyi Rih City AIDS Center  Henadiy Kruhlenko
Dnipropetrovsk Regional Drug Abuse Clinic Olha Lobachova
Regional Municipal Association "Phthysiology" Olena Vorontsova
Dnipro City Clinical Hospital №21 Olena Lisnycha
Dnipro City Hospital №2 Yuriy Sadovyi
Dnipro City Hospital №6 Valentyna Semyletova
Dnipro City Hospital №4 Larysa Sadova
Dnipropetrovsk Regional TB Hospital Artem Mazanko
Kryvyi Rih Mental Clinic Halyna Zheliznyak
Kryvyi Rih City Hospital №17 Iryna Kravtsova
Kryvyi Rih STI Clinic Serhiy Frolov
Kryvyi Rih TB Hospital №2 Pavlo Slobodenyuk
Kryvyi Rih City Hospital №8 Oleksiy Vitryak
Kryvyi Rih City Hospital №1 Kryvyi Rih City Hospital №1
Novomoskovsk City Hospital Nataliya Dibrova
Dniprodzerzhynsk City Primary Healthcare Center №3  Dniprodzerzhynsk City Primary Healthcare Center №3 
Dniprodzerzhynsk TB Hospital Oksana Reznyk
Ordzhonikidze City Primary Healthcare Center №3 Yuriy Mykhailov
Zhovti Vody City Medical Unit Olha Marinina
Pershotravensk City Hospital Svitlana Khomenko
Pavlohrad City Hospital №1 Lidiya Vasylenko
Pavlograd City TB Hospital Serhiy Shevchenko
Nikopol City Hospital №4 Alina Kosova
Nikopol City TB Hospital Alla Kryzhanovska
Ternivka City Hospital Nataliya Dryha-Maksakova
Apostolove Central Rayon Hospital Oleh Sheludko
Verkhnyodniprovsk Central Rayon Hospital Victoria Polynko
Dnipro Central Rayon Hospital Kateryna Nosenko
Novomoskovsk Central Rayon Hospital Iryna Hryhoriyeva
Nikopol Central Rayon Hospital Alla Kryzhanovska
Synelnykovo Central Rayon Hospital Olha Myrhorodska
Krynychky Central Rayon Hospital Svitlana Drobna
Kryvyi Rih Central Rayon Hospital Lyudmyla Filina
Pyatykhatky Central Rayon Hospital Valentyna Baitsurenko
Shyrokove Central Rayon Hospital Olena Safronova
Pavlohrad Central Rayon Hospital Nataliya Samarska
Pokrovsk Central Rayon Hospital Nataliya Orlova-Volkova
Marhanets Central Rayon Hospital Nataliya Vitko

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Evidence-based Interventions Supported by RESPOND

Intervention
Strengthening HIV Services Continuum at the ART Sites, Patient School, Opportunities Workshop, PLHIV Partner’s Health
NGO
Dnipropetrovsk Regional Branch of the PLHIV Network
Site
Dnipropetrovsk Regional AIDS Center, Dnipro City AIDS Center

 

Intervention
TB is Curable
NGO
Kryvyi Rih City AIDS Center
Site
Kryvyi Rih City AIDS Center

 

Intervention
Steps towards Health
NGO
Kryvyi Rih City Branch of the PLHIV Network
Site
Kryvyi Rih City AIDS Center, Kryvyi Rih STI Clinic, Kryvyi Rih Mental Clinic, Kryvyi Rih TB Hospital, City Hospitals №1 and №8 (ART sites), Kryvyi Rih Infectious Diseases Hospital №1, City Hospital №17 (ART sites), Kryvyi Rih Central Rayon Hospital

 

Intervention
PWID Partner’s Health
NGO
“Family Support Center”, Novomoskovsk
Site
Novomoskovsk City Hospital, Novomoskovsk Central Rayon Hospital, Pavlohrad City Hospital, Ternivka City Hospital, Dniprodzerzhynsk City Hospital

 

Milestones of the QI Collaborative in the Dnipropetrovska Oblast

  • On September 9, 2015, the MOU between RESPOND, UCDC, and Dnipropetrovsk Regional AIDS Center was signed to improve HIV care and treatment using the QI methodology. 
  • On October 24-25, 2015, a regional meeting was conducted for 45 healthcare managers and representatives of medical facilities and NGOs. Participants were introduced to the QI model and identified key areas for improvement of the treatment and care for PLHIV in the Dnipropetrovsk region. 
  • A training session for 37 QI coaches was conducted on November 10-13, 2015.
  • The QI Charter was developed and signed on February 2, 2016. The QI Charter includes the gap analysis, changes to be tested, and improvement activities. 
  • The first regional QI learning session was conducted for 37 QI teams/85 people on April 12-15, 2016. 
  • On April 25-27, 2016, RIG and the local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • The second regional QI learning session was conducted for 37 QI teams/88 people on June 14-17, 2016.
  • Forty computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • The following training were conducted during April-December, 2016:
    • On HCT (for 103 healthcare practitioners)
    • On ART basics (for 5 physicians)
    • On HIV/TB (for 23 physicians)
    • On prevention and treatment of opportunistic infections (for 10 physicians)
    • On quality improvement of HIV services (for 5 healthcare managers)
    • On leadership and change management for healthcare managers (for 7 head doctors and their deputies)
    • On quality improvement for the new ART sites (for 3 QI coaches)
    • On strengthening of the HIV services continuum (for 8 QI coaches)
  • Information materials on HCT and HIV treatment and blanks for records for patients and physicians were provided by RESPOND.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (over 197 in the period of November, 2015 – December, 2016)
  • On August 18, 2016, project outcomes have been presented during the Regional Coordination Board meeting, and praised by the Head of the Board
  • In January – March, 2017, there were 5 trainings for specialty physician nurses on HCT.
  • Training for 16 QI coaches on HIV+ status disclosure and involvement of PLHIV sexual partners to HCT was conducted on April, 11-12.
  • In March, 2017, the SIMS assessment was done at the following ART sites: NGO “Center for the Family Support” (Novomoskovsk city), cities of Ternivka, Pavlohrad, and at the Dnipropetrovsk Regional AIDS Center; all sites have received positive evaluation.
  • On March 27-29, 2017, RIG and the local QI teams took part in the third cross-regional QI learning session in Kyiv.
  • Training on involving PLHIV sexual partners to HTS conducted on April 11-12, 2017 for 16 local QI team members.
  • Focus group discussion with QI local team and RIG members as well as Chief Doctor of the Dnipropetrovsk Regional AIDS Center was made on May 25, 2017 within the Collaborative qualitative survey.
  • The fourth regional QI learning session was conducted for 39 on June 13-14, 2017.

 

 

 

QI Collaborative Change Package in the Dnipropetrovska Oblast (39 ART sites)

 

Gap

Change

Jan-Mar, 2016

Apr-Sept,

2016

Oct, 2016 – Mar, 2017

Apr-Sept, 2017

1. HIV testing and referral

1.2. HIV testing with two rapid tests or ELISA by specialists and/or PHC providers

Х

13

39

 

1.3. Make HTS info materials available for physicians and patients

Х

37

_

 

1.4. Implement a patient tracking system (vouchers, coupons or invitations)

Х

37

39

 

1.5. Provide escorting to patients by medical staff

Х

 
 

1.6. HTS for sexual partners of PLHIV

2

 

2. Linkage and enrollment in care

2.4. Return lab results (CD4 and viral load) to ART sites through Internet

_

6

_

 

2.6. Provide reminder text messages, phone calls or letters to patients

3

 

2.7. Provide active home visits by medical and social service providers

_

4

_

 

2.9. Registering patient PLHIV with AIDS service before they are discharged from the hospital

_

7

8

 

3. Treatment

3.2. Transfer patients on ART from AIDS Centers to local ART sites

_

3

3

 

3.8. Patient reminders to ensure ART adherence (quality assurance)

_

_

39

 

3.11. Assessment of ART adherence by physician at every patient visit

_

_

39

 

4. Cross-cutting

4.1. Implement electronic database for dynamic individual-level PLHIV service tracking

Х

37

_

 

4.2. Develop and implement regional and local referral protocols/patient pathways

Х

_

_

 

4.4. Train physicians and nurses on HTS

Х

37

 

4.6. Train physicians on HIV/TB co-infection treatment

_

25

_

 

4.7. Purchase of rapid tests from local/rayon budgets

_

2

_

 

4.8. Meetings of local QI teams at least monthly to analyze changes and data (with special attention to run charts)

_

37

_

 

4.9. Partnering with NGOs (escorting patients by social workers), to enroll PLHIV from key populations in medical care

Х

_

_

 

4.12. Simultaneous written consent for HTS and social support

_

_

15

 

Total Changes Implemented

9

14

7

 

Х – number of QI sites implementing the change is undefined

Key Achievements

  • Increased involvement of specialty physicians (TB doctors, narcologists, dermatologists, neuropathologists, oncologists, and so on) to HTS.
  • 7% increased share of HTS by specialty physicians (rapid tests and ELISA).
  • Increased share of HTS by specialty physicians using rapid tests (37% – narcologists, 39% – dermatologists, 15% – TB doctors, and doubled for PHC physicians).
  • Overall increase in HTS with rapid tests in the region – by 18%, and by 79% for at-risk groups.
  • Rapid tests purchased at the expense of Centers for Primary Healthcare.
  • Double time expanded network of healthcare facilities implementing written consent form for social support, from 15 to 30 by June 01, 2017.
  • Doubled number of PLHIV registered with AIDS service (482 in Apr-June, 2016 and 1009 in Apr-June, 2017).
  • Share of PLHIV registered with AIDS service is 98,4% of total new cases.
  • Timely registration with AIDS service for patients receiving ART at the TB and mental hospitals.
  • Involving of other healthcare services to registration of their in-patients with AIDS service before discharge.
  • 92% of new PLHIV are registered with AIDS service (about 150 ppl per month).

Challenges

  • Dependence of healthcare facilities from supplies of rapid tests by donor NGOs.
  • Delays in supply of rapid tests.
  • Patients refuse to sign consent form for social support (about 11% of refuses).
  • Impossibility to implement changes at those healthcare facilities that do not cooperate with NGOs and have no social worker position in staff.
  • Goals of the PEPFAR Plan on the number of patients initiated on ART are too high (4740 new patients in 12 months while this is 50% more than estimated number of PLHIV in the region by January 01, 2016).
  • ART site physicians do not want to increase their workload, and therefore the number of patients registered.
  • Some patients do not want to get ARVs by place of residence (risk of the HIV status disclosure, less experienced physicians).
  • A significant proportion of patients with high CD4 rate do not want to start ART.
  • Lots of patients quit treatment.

Next Steps

  • To promote rapid test purchase from local budgets.
  • To increase HIV testing efficiency.
  • To expand the number of healthcare facilities doing HTS with rapid tests.
  • Training on post-exposure prophylaxis for healthcare practitioners (especially nurses and paramedics).
  • To implement social support in other healthcare facilities, especially in hospitals.
  • To promote creation of social worker positions in healthcare facilities.
  • To actively initiate new patients on ART.
  • To control over ARVs balances.
  • To decentralize ART services so to redistribute workload between the physicians.
  • To conduct advanced trainings for ART site physicians.
  • To actively involve NGOs to the work on adherence to treatment.

Key Achievements

  • Extensive use of two rapid tests for HIV screening by PHC and specialty physicians, and involvement of nurses to HCT.
  • Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
  • Written consent for social support during HCT to prevent LTFU patients.

Challenges

  • Delays in supply of rapid tests.
  • Termination of William Clinton Foundation work in the Dnipropetrovsk region has resulted in the largest ART sites remain without rapid test systems.
  • Excessive workload of the ART site physicians.
  • Understaffing of the ART sites.
  • ART sites that fulfilled the PEPFAR plan now have no possibility for further initiation of patients on ART (no ARVs).
  • Delay in supply of ARVs from PEPFAR; the next delivery is scheduled for June, 2017.

Next steps

  • The practice of written consent for social support is to be extended to ART sites that do not implement this change.
  • Involve social workers to involving of patients to HCT, treatment, and adherence in the areas covered by NGO activities, and where increased number of patients on ART is expected.
  • Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment.
  • Control over categories of patients tested for HIV with two rapid tests at the PHC facilities.
  • To implement signing of written consent for social support during consent for HTS at the ART sites that do not implement this change.
  • Quality assurance: to assess adherence during every patient visit.
  • ART by PHC physicians.
  • Monthly fulfillment of the action plan to initiate patients on ART in collaboration with NGOs.

Key Achievements

  • Extensive use of two rapid tests for HIV screening by PHC and specialty physicians, and involvement of nurses to HCT.
  • Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
  • Written consent for social support during HCT to prevent LTFU patients.
  • Rapid tests purchased at the expense of Centers for Primary Healthcare.

Challenges

  • Delays in the supply of rapid tests.
  • Excessive workload of the ART site physicians.
  • Understaffing of the ART sites.
  • NGOs do not provide services in some rayons outside Dnipropetrovsk.

Next steps

  • The practice of written consent for social support is to be extended to ART sites that do not implement this change. 
  • Involve social workers to cooperation with healthcare practitioners in terms of enrollment to HCT, treatment, and adherence in the areas covered by NGO activities and where increased number of patients on ART is expected. 
  • Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment. 
  • Control over categories of patients tested for HIV with two rapid tests at the PHC facilities.

Key Achievements

  • HTS with two rapid tests for urgent informing of the patient in case of HIV-positive status and further registration with AIDS service.
  • Implemented method of registering with AIDS service the HIV-positive in-patients before they are discharged from the hospital.
  • Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
  • Written consent for social support during HCT to prevent LTFU patients.

Challenges

  • Delays in the supply of rapid tests and ELISA testing systems in the region.
  • Absence of NGOs in some rayons of the Dnipropetrovsk region
  • Excessive workload of the ART site physicians.
  • Understaffing of the ART sites.

Next steps

  • To involve secondary healthcare facilities to implementation of the written consent for social support. 
  • To involve social workers to cooperation with healthcare practitioners in terms of enrollment to HCT, treatment, and adherence in the areas covered by NGO activities and where increased number of patients on ART is expected. 
  • Scale-up effective QI changes to the ART sites that don’t implement them.
  • Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment. 

Key Achievements

  • Improved cooperation between healthcare facilities and NGOs, cooperation agreements are signed with all the PHC facilities in the cities of Dnipro and Kryvyi Rih.
  • ART sites staff involved to patient data input to the STMA.
  • Position of the Infectious Disease (ID) Specialist is introduced within TB hospital so to register with AIDS service the HIV-positive in-patients before they are discharged from the hospital.
  • Developed algorithm of transfer of patients from regional and city AIDS centers to rayon ART sites.

Challenges

  • Delays in the supply of rapid tests and ELISA testing systems in the region.
  • Absence of NGOs in some rayons of the Dnipropetrovsk region
  • Excessive workload of the ART site physicians.
  • Understaffing of the ART sites.

Next steps

  • Scale-up social support by NGOs to those rayons that are not currently covered with this service. 
  • Intensify decentralization process at the Dnipro City AIDS Center and Kryvyi Rih City AIDS Center (transfer of patients to local ART sites).
  • Involve alternates to STMA keeping. 

Key Achievements

  • PHC facilities involved to HIV screening.
  • Simultaneous written consent for HTS and social support (Kryvyi Rih).
  • HTS with two rapid tests for urgent informing of the patient in case of HIV-positive status and further registration with AIDS service.
  • Registering with AIDS service the HIV-positive in-patients of the Dnipro City Mental Clinic and TB Hospital.
  • Position of the psychologist is introduced within Pyatykhatky Trust Office.
  • Rapid tests and ELISA testing systems purchased at the expense of local budget.

Challenges

  • Linkage to care gap.
  • Difficulties with involving of the specialty and PHC physicians to HCT.
  • Lack of support from city and rayon coordination councils in terms of HIV services.

Next steps

  • Intensify involving of the specialty and PHC physicians to HCT.
  • Involve NGOs to cooperation with healthcare facilities.

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HIV Screening, 2015-2017

HIV Detection: Number and Proportion Tested Positive, 2015-2017

Registration at AIDS Service and Initiation on ART, 2015-2017