QI COLLABORATIVE OVERVIEW

To improve the continuum of HIV services, from HIV testing to linkage to care, treatment and support for PLHIV in the Kirovograd region, a Quality Improvement Collaborative was established in July, 2016.

In September 2016, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Kirovograd Regional Healthcare Department. According to this order, five 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 branch of the CF “100% of Life Network”.

Regional QI Implementation Group (RIG): Regional Coordinator – Halyna Horenko, QI Mentor – Nadiya Shutova, Data Quality Mentor – Iryna Babiy.
 

Site QI Coach
Kirovograd Regional AIDS Center Olena Khomyak
Dolynska Central Rayon Hospital Victor Shovkoplyas
Novoukrainka Central Rayon Hospital Lyudmyla Kovalyova
Mala Vyska Central Rayon Hospital Alla Rudenko
Oleksandriya Central City Hospital Lyudmyla Zdanovska

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO

Strengthening HIV Services Continuum
at the ART Sites 
CF “100% of Life Network”
Kherson X
Kakhovkа X
Nova Kakhovka X
Tsyurupynsk X
Skadovsk X
Velyka Lepetykha X
Gola Prystan X
Velyka Oleksandrivka X

 

Milestones of the QI Collaborative in the Khersonska Oblast

  • 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 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 Kirovograd Region (5 ART 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 specialty physicians and/or PHC providers

_

_

5

 

1.7. Assess behavioral risks and clinical indicators, and provide HTS for in-patients within the first three days of hospitalization

_

_

5

 

2. Linkage and retention in care

2.9. Registering with AIDS service the HIV-positive in-patients before they are discharged from the hospital

_

_

5

 
 

3. Treatment

3.1. Initiation and management of ART at ART site

_

_

5

 

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

_

_

1

 

4. Cross-cutting

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

_

_

5

 

4.2. Develop and implement region

al and local referral protocols/patient pathways

_

_

5

 

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

_

_

3

 

4.4. Train physicians and nurses on HTS

Х

 

4.5. Train physicians on ART

Х

 

4.7. HIV rapid tests purchasing by a local/district budget

_

_

5

 

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

_

_

5

 

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

_

_

5

 

Total Changes Implemented

12

 

Х – number of QI sites implementing the change is undefined

Key Achievements

  • Successful QI changes (like providing necessary lab tests during one patient visit, extended operating time for Trust Offices and ART sites, and returning of lab test results via Internet) contributed to registering of 95% of PLHIV, of which, 80% started treatment.
  • The number of PLHIV initiated on ART at eleven ART sites in the region has almost doubled (the last one ART site at the Genichesk District Hospital is about to start the change in July-August 2017).
  • 89% of patients on ART has undetectable viral load (less than 40 copies).
  • Kherson region fulfilled the PEPFAR plan on ART uptake.
  • Trust Offices staff was trained on involving of PLHIV sexual partners to HCT.

Challenges

  • Delays in ART supplies.
  • Shortage of ART combinations without Efavirenzum (important for those working at night hours).
  • MIS program is not implemented yet.
  • Delays in healthcare reform in the region; combination and functions of healthcare districts are not identified yet.

Next steps

  • Training for nurses on providing and monitoring of adherence to ART.
  • Finalizing and signing of the MoU and QI Charter in the region.
  • Continue implementing of QI changes aimed at reducing of gaps in linkage to care and treatment.
  • Continue RIG mentoring visits to QI sites in the region.

Key Achievements

  • Rapid tests for Mala Vyska ART site purchased from local budget.
  • Successful decentralizing of two ART sites in Oleksandriya city and Novoukrainka rayon; initiation on ART and scheme management is now made directly at the ART site.
  • Specialty physicians and PHC practitioners involved to risk behavior screening.
  • HIV detection rate remains stable (5,4% in Jan-Mar, 2017 against 4,4% in Oct-Dec, 2016).
  • Number of PLHIV registered with AIDS service has almost doubled in comparison with the previous quarter (62 people against 35 in October-December).
  • Number of PLHIV initiated on ART has 10% increase compared with Oct-Dec, 2016.
  • Regional Coordination Council on TB, HIV, and AIDS obliged municipal and rayon administrations to purchase rapid tests at the expense of local budgets.

Challenges

  • Lack of rapid tests in some rayons.
  • Lack of ART sites in the region.
  • Difficulties with implementation of the Medical Information System (MIS).
  • Incomplete decentralization of the Dolynka and Mala Vyska ART sites (sites dispense ARVs only).
  • Understaffing of some rayon ART sites.
  • Lack of the regional lab for CD4 and viral load testing.

Next steps

  • To purchase rapid tests for Novoukrainka ART site and Kropyvnytsyi (fromer Kirovograd) PHC Center at the expense of local budget.
  • To introduce positions of the infectious disease doctor and social worker at the Mala Vyska ART site.
  • To strengthen capacity of the ART sites staff to run MIS.
  • To optimize transportation of blood samples to another region for viral load and CD4 testing.

Key Achievements

  • Three new ART sites are opened in the cities of Oleksadriya, Mala Vyska, and Novoukrainka.
  • All five ART sites started piloting changes.
  • Specialty physicians and PHC physicians are involved to rick behavior screening.
    • It has increased the number of patients referred for HTS.
    • 78,2% of the total number received provider-initiated HTS in Novoukrainka rayon were referred by the specialty physicians.
    • Detection rate in Mala Vyska and Dolynska rayons has increased from 2,7% to 6,3% in Oct-Dec, 2016 in comparison with Oct-Dec, 2015.  
  • Five ART sites receive the social support services from the regional branch of the CF “100% of Life Network”.
  • Regional AIDS Center has started the transfer of patients on ART to the local ART sites. Thus, as of February 1, 2017, 66% of patients on ART (or 92 out of 140) living in Oleksandriya City receive ART at the local site. 
  • Two out of four rayon ART sites started initiating on ART. 
  • Regional State Administration has issued an order to revise the rayon budgets so to allocate funds to purchase the rapid tests. 

Challenges

  • Lack of rapid tests in some rayons.
  • Belated data input to the STMA, and only four ART sites do this.
  • Necessity to deliver blood samples to other regions for CD4 and viral load analysis.

Next steps

  • To elaborate and introduce the clear schedule for inputting data to STMA in timely manner.
  • To set treatment goals for five ART sites for 2017.
  • To lobby the order of the Regional State Administration on allocating funds from local budgets to purchase the rapid tests. 

Challenges

  • Lack of rapid tests in the region.
  • Small number of the ART sites in the region.
  • Issues transporting blood samples from rayons to AIDS Center. 
  • Problems with data collecting and analyzing. 
  • Low rates of detection, registration, and initiation on ART in the region.
  • Lack of NGOs in some rayons.

Next steps

  • To open three new ART sites (through end 2016)
  • Identify changes for piloting at the ART sites.
  • To involve specialty physicians to HTS.
  • Scale-up the work of NGOs to the rayons where ART sites are opened.
  • Data collection and analysis using the STMA.

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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