quality improvement in hiv treatment services in rwanda ( using the existing electronic recording...
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Quality improvement in HIV treatment services in Rwanda ( using the existing electronic recording and reporting systems), and the transition of these services from international partners to MOH.
Endris Mohammed1,2, Byringiro Vianney2, Sabin Nsanzimana2
1: Rwanda Family Health Project
2: Rwanda Bio Medical Center (RBC)
IAS 2013, Kuala lumpur, Malaysia July 1, 2013
Outline
Country profile Track 1.0 transition in Rwanda RBC/IHDPC/HIV division QI program overview Rwanda electronic recording and reporting
system QI program strategies-real time accessible
health data driven Selected results Conclusions Lessons Learned & recommendations
Rwanda at a Glance
• Total Population: approx. 11 million
• HIV Prevalence: 3% (2010 DHS)
• Total No. of patients on ART by the end of April 2013: 118,657 (> 94% of those in need)
• Total number of health facilities: 510• 486 PMTCT sites• 490 VCT sites• 458 ART sites
By the end of April 2013
Track 1.0 Transition in Rwanda
• CDC-Rwanda began transitioning financial and technical responsibilities for HIV clinical services at 76 Health Facilities from international NGOs to MoH-Rwanda in 2010
• Transition completed by February 2012
• Financial and clinical performance of transitioned sites monitored every 6 months
• MOH-Rwanda and HEALTHQUAL developed site-level QI program in March 2011 to help maintain the quality of clinical care
May Jun
eJuly
Aug.Sept Oct
. Nov.Dec.
Jan.Feb. March
April MayJune July Aug.
Sept.
2010 2011
Cohort 1 Transition*18 Sites
Cohort 2 Transition6 Sites
Cohort 3 Transition26 Sites
C1 Baseline C1 6- Month FU C1 12-Month FU
C2 Baseline C2 6-Month FU
C3 Baseline
Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda
C3 6-Month FU
Cohort 3.5 Transition**20 Sites
C3.5 Baseline
**The financial transition for Cohort 3.5 sites will occur in March 2011
C3.5 6-Month FU*The Cohort 1 transition occurred in March 2010
Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda
Oct. Nov
.Dec.
Jan.Feb. Marc
h AprilMay June
July Aug.Sept.
Oct.Nov.
Dec.Jan.
Feb.
2011 2012
C1 18-month FU C1 24- Month FU
C2 12-Month FU C2 18-Month FU
C3 12-Month FU
C2 24-Month FU
Cohort 4 Transition6 Sites
C4 Baseline C4 6-Month FU
C3 18-Month FU
2013
C3.5 12-Month FU C3.5 18-Month FU
March
C4 12-Month FU
C3 24-Month FU
C3.5 24-Month FU
List of clinical indicators used in the transition assessment
1. The proportion of HIV+ pregnant women eligible for triple therapy prophylaxis who received triple therapy prophylaxis
2. The proportion of HIV+ pregnant women eligible for triple therapy for life who received triple therapy for life
3. Proportion of partners of pregnant women presenting for their first antenatal care consultation who are tested for HIV
4. Proportion of infants born to HIV+ mothers who received ART prophylaxis at birth
5. Proportion of infants born to HIV+ mothers that have PCR at the age of 6 weeks
6. Proportion of currently enrolled patients on Pre-ART and ART who are on CTX
List of clinical indicators used in the transition assessment conti…
1. The proportion of ART patients who are still on treatment 12 months after initiation
2. The proportion of patients newly enrolled in HIV services who were screened for TB
3. Number of patients newly initiating on ART during the reporting period a. Pediatric patients b. Adult patients
4. Number of patients currently on ART at the end of the reporting period
5. Proportion of patients who received ARVs for 12 out of 12 months
6. Proportion of ART patients who received CD4 control at 6 months
RBC/IHDPC/HIV Division QI Program Overview
Goals: Improve and sustain quality of HIV/AIDS clinical
services at health centers and district hospitals. Build national capacity in quality management Maximize utilization of National & facility level
electronic recording & reporting systems to identify areas for QI
Integrate QI in the existing clinical mentorship system
QI team Coordinates, monitors implementation Selects sites for inclusion based on transition
monitoring data & priorities of MoH Phased approach to implementation: 9 sites in first phase
The Electronic recording & reporting system
Facility level recording systems: IQ chart Open MRS
National level reporting system Tracnet
CellPhone
PCs/Internet
PDA/Smartphone
SAMPLE DATA
A GoR information system that supports the national HIV/AIDS and other health programs.
Builds on existing telecommunications infrastructure
Allows TRACplus to:• Collect real-time information
from the field via web, phone, mobile application, paper...
• Communicate and send alerts and information back out to the field in a timely and systematic way.
• View Rapid visualization of data – in charts, tables, graphs and dashboards
LocalApplications
Phone
TRACnet:
Program Strategies
Baseline and follow up data & trainingSource: Trac net, IQ chart and Open
MRS Validation of clinical performance data Site-level prioritization, gap analysis &
changes to improve care Coaching Visits Peer learning meetings
Selected QI Clinical Indicators
• % infants born to HIV INFECTED mothers who are tested for HIV using DNA PCR at 6-8 weeks
• % HIV INFECTED pregnant women that receive ARV prophylaxis
• % lost to follow ups among patients in Pre-ART care who are enrolled into care 4-15 months prior to assessment period
• % ART patients still on treatment 12 months after initiation
• % patients on ART who receive CD4 cell count measurement 6 months after being initiated on ART
• % patients who received ARVs for 12 out of 12 months
Coaching visits
• Onsite training
• Monthly & quarterly visits
• Quarterly data validation exercises• QI indicators• Tracnet indicators
May Jun
eJuly Aug.
SeptOct
.Nov. Dec. Jan.
Feb.March
AprilMay June
2011 2012
Basic QI Training9 Sites
Coaching Visits9 Sites
Performance Measurement Training9 Sites
Baseline Data Collection9 Sites
9 Month Data Collection9 Sites
Data Validation9 Sites
6 Month Data Collection9 Sites
QI Project Activities & Timeline
Baseline Data Collection15 Sites
Examples of Site level Identified Gaps
• Lack of harmonized appointment system
• In adequate provider & patient appointment reminder system
• Appointment registers with list of expected patients-not available: • CD4 & clinical follow up visits
Examples of Site level Identified Gaps conti…
In sufficient use of the ARV drug pick up appointment book ( table on the next slide)
Lack of early patient tracking mechanism Relatively long waiting time in some clinics Patient- level service satisfaction survey
Not routinely conducted Utilization of site level data:
to systematically improve quality of service
The existing appointment register: for ARV drug pick up
No.
Name Trac net Number
ART regimen/cotrimoxazole
Examples of QI Interventions
Site Level:• Waiting time reduced• Patient with missed appointments contacted early• 2 days after the actual date of appointment
• Grouping of patients for appointments (table on the next slide)
Examples of QI Interventions conti…
• Easy identification of patients with repeated missed appointments
• Solicited feedback from patients • Harmonized clinic visits• Utilization of site level data :
• Using QI approaches and methodsNational Level:• QI integrated in clinical mentorship guideline & program
Appointment system: with grouping of patients
Identification
Trac Net Number
Sex
Age Date of appointment ( mark √ if patient comes on the exact date, if not leave it blank & write the date when she/he comes in the blank space
Next Date of appointment
Next date of appointment
Next date of appointment
Next Date of appointment
Next Date of appointment
% ART Patients Received CD4 cell count measurement6 months after ART Initiation: Kigali sites
% ART Patients Received CD4 cell count measurement
6 months after ART Initiation: Nyamasheke sites
Conclusions
• QI program improves country capacity & ownership by supporting MOH staff & health workers to: • incorporate performance data, patient
feedback and, a system approach to improve quality of care
• utilize real time accessible health data for decision making
• The 6,9, 12, 18 and 24 months follow up data show improved results on CD4 control indicator
Lessons Learned and Recommendations
Improvement goals can be achieved
Leadership: a key component to support site-level program ownership
Patient feedback enhances improvement effort
MoH-Rwanda Scale-up QI to additional facilities, Develop district level pool of coaches
Acknowledgements
• MoH Rwanda• RBC/IHDPC/HIV Division • HQ-I• CDC-Rwanda• The pilot sites• ICAP• IHV/UMB
Thank You Murakoze
Merci