QI COLLABORATIVE OVERVIEW

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

In February 2016, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Kherson Regional Healthcare Department. Between December2015 and January 2016, ten local QI teams were created around the existing ART sites. 

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 “Mangust” and “XXI Stolittya”.

In February-March 2016, two new ART sites were established with local QI teams around them.  

Regional QI Implementation Group (RIG): Regional Coordinator – Yaroslav Zyatiuk, QI Mentor – Victoria Savchenko, Data Quality Mentor – Tetiana Rezvyh.
 

Site QI Coach
Kherson Regional AIDS Center Natalia Ryzhenko
Dniprovskyi rayon Tetyana Tyshchenko
Komsomolskyi rayon Halyna Pavel
Suvurovskyi rayon Olha Demedyuk
Beryslav Nelya Dubova
Velyka Lepetykha Olena Rudenko
Velyka Oleksandrivka Oksana Moskalenko
Henichesk Remzi Kurtametov
Kakhovka Taras Zalypka
Nova Kakhovka Lyubov Holovatyuk
Novovorontsovka Iryna Shamrai
Tsyurupynsk Vitaliy Yukhymenko

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO

PWID Partner’s Health,
“Mangust”
Charitable Foundation
PLHIV Partner’s Health
“XXI Stolittya”
Charitable Foundation
Kherson X X
Kakhovkа X X
Nova Kakhovka X X
Tsyurupynsk X  
Skadovsk X  
Velyka Lepetykha X X
Gola Prystan X  
Velyka Oleksandrivka   X

 

Milestones of the QI Collaborative in the Khersonska Oblast

As part of the QI collaborative to reduce the gaps in the cascade was taken the following steps:

  • On June 24, 2015, the MOU between RESPOND, UCDC and Kherson Regional AIDS Center was signed to improve HIV care and treatment using the QI methodology. 
  • On October 14-15, 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 Kherson region. 
  • A training session for 11 QI coaches was conducted on November 23-25, 2015.
  • The QI Charter was developed and signed on December 21, 2015. It was approved by Kherson Regional Healthcare Department, Kherson Regional AIDS Center, “Mangust” Charitable Foundation, regional branch of the All-Ukrainian Network of PLHIV, and Kherson Regional Center for Family, Children, and Youth Social Services. The QI Charter includes the gap analysis, changes to be tested, and improvement activities. 
  • The first regional QI learning session was conducted for 11 QI teams/50 people on March 30-31, 2016. 
  • On April 25-27, 2016, RIG and the best local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • Ten computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • Trainings on HCT and HIV/TB were conducted for the 19 teams of healthcare practitioners in May-June, 2016.
  • The second regional QI learning session was conducted for 12 QI teams/50 people on July 7-8, 2016.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (over 60 in the period of November, 2015 – December, 2016)

 

 

 

QI Collaborative Change Package in the Khersonska Oblast (12 ATR sites)

Gap

Change

Jan-Mar, 2016

Apr-Sept,

2016

Oct, 2016 – Mar, 2017

Apr-Sept, 2017

1. HIV testing and referral

1.1. HIV risk assessment by specialists and/or PHC providers

Х

5

12

 

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

Х

11

12

 

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

_

4

_

 

1.5. Provide escorting to patients by medical staff

8

 

1.6. HTS for sexual partners of PLHIV

Х

5

 

1.8. Double coding at the time of HTS to ensure identification of PWID

_

12

_

 

1.9. Redistribute responsibilities on HTS among doctors and nurses

_

11

_

 

1.11. External quality assessment of rapid HIV testing (quality assurance)

_

_

3

 

2. Linkage and retention in care

2.1. Provide the required lab tests (ELISA II, CD4 and blood chemistry) over one patient’s visit/ to the Trust Office/ART site

_

11

_

 

2.2. Extend/adapt the working hours of Trust Offices/ART sites

_

11

_

 

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

_

11

11

 
 

3. Treatment

3.1. Initiate and manage ART at ART site

Х

5

4

 

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

_

_

1

 

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

_

_

12

 

4. Cross-cutting

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

Х

_

12

 

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

Х

_

_

 

4.3. Increase the network of active Trust Offices/ART sites

Х

2

_

 

4.4. Train physicians and nurses on HTS

Х

37

 

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

Х

_

_

 

Total Changes Implemented

8

13

9

 

Х – number of QI sites implementing the change is undefined

Key Achievements

  • Collecting and analysis of data using STMA.
  • HCT by specialty physicians.
  • All the ART sites use rapid tests for HCT.
  • Ten out of twelve ART sites initiate patients on ART.
  • Continued mentoring and RIG visits to the priority ART sites.
  • Successful changes increased ART coverage among PLHIV registered with AIDS service.

Challenges

  • Not all the ART sites initiate patients on ART.
  • Specialty physicians use risk behavior screening in two different ways: self-assessment questionnaire + interview with physician and risk behavior screening algorithm.
  • Poor cooperation between AIDS service and STI and narcology services because of poor motivation and counselling skills among specialists.
  • NGOs provide services only in three rayons (Tsyurupinsk, Beryslav, and Kakhovka) and one city (Nova Kakhovka) outside Kherson city.
  • Understaffing of the ART sites in the region.

Next steps

  • To expand ART coverage to Dniprovsky rayon ART site since June, 2017.
  • To pilot questionnaire on adherence to ART.
  • To keep on with HIV rapid testing quality assurance.
  • To implement risk behavior screening at all the ART sites and expand it to PHC facilities.
  • Update MoU using QI methodology through 2020.

Key Achievements

• PDSA cycles are fine-tuned, and the number of changes is decreased to raise implementation quality;
• Implemented changes on data collection and analysis (STMA);
• Specialty physicians started HCT;
• Rapid HIV tests started to be used;
• Two new ART sites launched;
• Three sites started initiating ART independently;
• All QI sites received mentoring visits from the RIG;
• Local protocols are revised so that all the necessary lab tests are made over one patient visit to the Trust Office/ART site;
• The changes contributed to increasing the PLHIV registration rate with AIDS service;

Challenges

• Not all QI sites initiate ART;
• Not all QI sites follow the methodology of using and storing the rapid testing kits;
• Specialty physicians from different sites do not have the common approach to risk behavior screening;
• Poor liaison between the STI, narcological service and the AIDS service because of lack of motivation and poor counselling skills;
• NGOs do not provide any services outside Kherson (especially, on the adherence to treatment);

Next steps

• Since February 2017, initiation on ART is to be implemented at all QI sites;
• Pilot a patient questionnaire on ART adherence;
• Monitor the storage and use of rapid test kits at all sites;
• Introduce risk behavior screening at all sites;
• Update the regional QI Charter through 2020;

Key Achievements

• Local teams’ meetings are regular and systematic;
• 97% of patients do receive all the lab tests required for registration with AIDS service during one patient visit to ART site, which increased the share of registered patients to 92%;
• Novovorontsovka rayon ART site have reached 100% of initiation on ART among new patients;

Challenges

• Low overall level of initiation on ART among new patients;
• Poor HIV detecting by specialty physicians;
• Initiation on ART is made only in the regional AIDS Center and three ART sites;

Next steps

• Involve ART sites to treatment initiation;
• External assessment of the HTS with rapid tests by local QI team members;
• Assessment of adherence to ART within all the regional ART sites;

Key Achievements

• HIV risk assessment implemented at three QI sites resulted in 3% growth of the HIV detection rate;
• Increased HIV detection rate at the Tsyuryupinsk QI site: 11% using rapid tests and ELISA, and 12% using rapid tests only;
• Rapid tests purchased at the expense of rayon budgets;
• Three ART sites initiate treatment on site (32 patients have been initiated on ART directly at the sites during January-June, 2016);
• HCT is done by nurses, not physicians;
• Turn-around time of test results between ART sites and the lab is two days;
• Local protocols and patient pathways are developed at all the 11 sites;

Challenges

• Shortage of rapid tests caused by delay in delivery resulted in low yield of testing at the site;
• Low HIV detection rate at some ART sites;
• Shortage of ARVs in the region;
• Irregular or incomplete input of data into STMA;
• Visualization, analysis, and using of data at the local level are to be improved;

Next steps

• All the local teams implement risk behavior screening;
• Kakhovka rayon local team starts initiation on ART directly on ART site;
• Local teams continue to implement changes, collect and analyze data;

Key Achievements

• Two new ART sites started to work;
• Rapid tests purchased at the expense of rayon budgets;
• Increased HIV detection rate in Kakhovka rayon (10%);
• HCT is done by nurses at the three ART sites;

Challenges

• Poor liaison between the dermatological and/or narcological service and the AIDS service because of lack of motivation and poor counselling skills;
• To identify the key target groups at the rayon level;
• NGOs do not provide services in some rayons outside Kherson;

Next steps

• Double coding for proper PWID tracking;
• To involve two another ART sites to the QI Collaborative;
• HTS with two rapid tests;

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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