KYIV REGION QI COLLABORATIVE OVERVIEW

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

In December, 2016, the QI Charter was signed between the Kyiv Regional Healthcare Department and partners on Collaborative implementation. The Charter defines composition of the Regional QI Implementation Group, QI Mentors, and local QI teams. Between December, 2015 and January, 2016, thirteen 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, PHC providers, and social workers of the regional branch of the CF ‘100% Life Network’ and CF ‘Convictus Ukraine’.

Regional QI Implementation Group (RIG): Regional Coordinator – Svitlana Khotina, QI Mentor – Inna Khodus, Data Quality Mentor – Olesya Pogorelova.
 

Site

QI Coach
Bila Tserkva Central Rayon Hospital Inna Dedenistova
Brovary Central Rayon Hospital  Halyna Olevska 
Irpin Central City Hospital  Danylo Sheykin
Boyarka Central Rayon Hospital  Ruslana Khortyk
Fastiv Central Rayon Hospital Oleksandra Zhabenko
Kyiv Regional AIDS Center Inna Khodus
Vyshgorod Central Rayon Hospital Serhiy Soltys
Myronivka Central Rayon Hospital Olha Maydannyk
Obukhiv Central Rayon Hospital Volodymyr Chernyushok
Rzhyshiv City Hospital Lyudmyla Dzenenko
Vasylkiv Central Rayon Hospital Ramil Bakhmutov
Kyiv Regional TB Hospital (City of Boyarka) Svitlana Kartashova
Bila Tserkva Central Rayon Hospital Vasyl Shramenko
Rokytne Central Rayon Hospital Larysa Bednaya
Makariv Central Rayon Hospital Tetyana Yovenko
Yahotyn Central Rayon Hospital Alla Chub
Pereyaslav-Khemelnytsyi Central Rayon Hospital Lesya Bordun
Ivankiv Central Rayon Hospital Oleksiy Glushenko
Borodyanka Central Rayon Hospital Oleh Dzhus

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO
Strengthening HIV Services
Continuum at the ART Sites
(including Patient School,
Steps Towards Health,
PLHIV Partner’s Health)
100% of Life Network. Kyiv region		 PWID Partner’s Health 
Convictus Ukraine
Trust Office at the Bila Tserkva
Central Rayon Hospital №2		 X  
Trust Office at the Obukhiv
Central Rayon Hospital		 X  
Trust Office
at the Pereyaslav-Khmelnytskyi
Central Rayon Hospital		 X  
Trust Office at the Borodyanka
Central Rayon Hospital		 X  
Trust Office at the Ivankiv
Central Rayon Hospital		 X  
Bila Tserkva   X
Borodyanka   X
Boyarka   X
Brovary   X
Vasylkiv   X
Irpin   X
Fastiv   X

 

Milestones of the QI Collaborative in Kyiv Region

  • In June, 2015, the MOU between RESPOND, UCDC, and Kyiv Regional Healthcare Department was signed to improve HIV care and treatment using the QI methodology.
  • On October, 8-9, 2015, a regional meeting was conducted for 32 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 Kyiv region.
  • A training session for 11 QI coaches was conducted on December 14-16, 2015.
  • The QI Charter was developed and signed on December 23, 2015. The QI Charter includes the gap analysis, changes to be tested, and improvement activities.
  • The first regional QI learning session was conducted for 13 QI teams/35 people of the Kyiv region on April 19-20, 2016.
  • On April 25-27, 2016, the RIG and local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • The second regional QI learning session was conducted for 13 QI teams/30 people on July 27-28, 2016.
  • Twenty-one computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • 69 healthcare practitioners took part in the training on HCT and HIV/TB co-infection.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • The following trainings were conducted during April-December, 2016:
    • On HCT – 72 healthcare practitioners trained.
    • On HIV/TB – 23 physicians trained.
    • On QI of HIV services – 2 healthcare leaders.
    • On leadership and management of changes – 5 healthcare leaders.
    • On QI for new ART sites – 9 coaches.
    • On cooperation in local QI team – 3 RIG members.
  • The third regional QI learning session was conducted for 19 QI teams/34 people on December 20-21, 2016.
  • Training HIV status disclosure and involving PLHIV sexual partners to HTS conducted on February 8-9, 2017 for 7 members of local QI teams.
  • SIMS assessment was conducted at the ART sites of the Kyiv Regional AIDS Center and Bila Tserkva City Hospital №3; both sites were highly evaluated positively.
  • The fourth regional QI learning session was conducted for 19 QI teams/42 people on June 29-30, 2017.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (62 in the period of January, 2016 – June, 2017).

 

 

 

 

QI Collaborative Change Package in the Kyiv Region (20 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 specialists and/or PHC providers

–

10

_

 _

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

_

5

4

 5

1.3. Make HTS info materials available for physicians and patients

_

13

_

 _

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

–

11

15

–

1.5. Provide escorting to patients by medical staff

–

13

–

_

1.6. HTS for sexual partners of PLHIV

Х

4

–

–

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

Х

2

–

–

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

–

13

–

–

1.9. Redistribute responsibilities on HTS among doctors and nurses

–

10

–

–

1.10. Medical provider-initiated HIV counseling and testing

13

–

–

19

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

–

–

5

5

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

Х

10

_

–

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

Х

–

–

–

2.3. More frequent transporting of biomaterial to the lab

Х

3

–

–

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

_

_

18

19

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

Х

12

–

–

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

Х

11

–

–

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

_

11

1

18
 

3. Treatment

3.1. Initiate and manage ART at ART site

_

10

–

–

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

Х

10

–

1

3.4. Manage ART stock at ART site, including dispensing of ART through pharmacies

–

10

–

–

3.5. Optimize ART dispensing practices/Dispense three to six-month supply of ART

_

6

–

–

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

–

–

5

5

4. Cross-cutting

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

Х

13

_

–

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

8

_

–

4.4. Train physicians and nurses on HTS

Х

10

_

–

4.5. Train physicians on ART

–

7

–

–

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

_

7

_

–

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

Х

13

_

–

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

_

11

_

–

4.11. Setting up a Trust Line in the region

_

2

_

–

4.12. Simultaneous written consent for HTS and social support

_

13

_

–

Total Changes Implemented

13

27

6

7

Х – number of QI sites implementing the change is undefined

Key Achievements

  • RIG efforts are aimed at ensuring sustainability of the HIV-service in the healthcare reform. This issue has been discussed on a meeting between QI coaches, Head of the Department of Health in the Kyiv region in September 2017. Prepared recommendations for Chief Doctors of the ART sites on providing HIV-services in hospital district.
  • In July-September, the number of people tested for HIV increased from 3,679 to 3,879 in comparison with the previous quarter. Number of ART patients increased from 3,718 to 3,907.
  • 255 people initiated on ART at ART site.

Challenges

  • Understaffing remains the main problem of ART sites.
  • Lack of clear organization of HIV-service in healthcare reform.
  • Poor motivation of PHC providers and specialty physicians to providing HTS.
  • Patient prejudice towards ART and unwillingness to receive ART at place of residence.

Next Steps

  • Continue training of PHC providers and specialty physicians on ART, HTS, and decreasing the HIV-related stigma and discrimination among healthcare practitioners.
  • On the level of the Health Department, develop and approve the structure of HIV-service in the Kyiv region.
  • Continue monitoring over ART sites.
  • Motivate NGO to expand activity to other ART sites in the Kyiv region.
  • Support the Coordination Councils and Hospital Councils in fighting HIV/AIDS in the region.
April - June, 2017

Key Achievements

  • RIG made nine mentoring visits and seven for data verification; there also were two monitoring visits by USAID within the SIMS assessment.
  • Increased number of people tested in comparison to the Apr-June, 2016: 3,679 against 3,443.
  • Continued decentralization of HIV services; during Jan-June, 2017, 149 patients have been transferred to local ART sites.
  • 48,8% increased treatment rate in comparison to the Apr-June, 2016 (1,220 people more).
  • Fourteen members of the local QI teams received training on HCT and basics of initiation on ART.

Challenges

  • Delays in supplies of the rapid HIV test kits.
  • High turnover of the Trust Office medical stuff.
  •  Poor motivation of specialty physicians and PHC physicians to providing HTS.
  • Patients do not want to be transferred to the domiciliary ART sites because of possible stigmatization.
  • Lack of fuel for biomaterial transporting, which is currently made once per 1-2 weeks and complicates HIV testing.
  • QI Coaches work part-time at the most sites.
  • Some patients are prejudiced to ART.

Next steps

  • Continue trainings on HCT for PHC practitioners, specialty physicians, and inpatient department doctors, and involve them to HIV screening.
  • Support sustainability of the QI initiatives  (meetings and recommendations to chief physicians, cooperation with the Healthcare Department).
  • Quality assurance in the following areas: risk behavior screening, HIV screening, and improving adherence to treatment.
  • Due to the action plan, continue mentoring visits to the RT sites and monitoring of the PDSA change implementation.

Key Achievements

  • During the joint project with RESPOND, the number of the ART sites in the region has increased from 13 to 19.
  • Allocated additional renovated premises for the following ART sites: Borodyanka Central Rayon Hospital, Pereyaslav-Khmelnytskyi Central Rayon Hospital, Bila Tserkva Central Rayon Hospital, and Yahotyn Central Rayon Hospital.
  • Specialty physicians started providing HTS at the following ART sites: Obukhiv, Bila Tserkva, Irpin, Vasylkibv, and Vyshgorod.
  • Cooperation between the NGO social workers and physicians has been established at the following ART sites: Ivankiv, Borodyanka, and Obukhiv.
  • Five QI Coaches were trained on initiation on ART.
  • Continued decentralization of HIV services; during Jan-Mar, 2017, 72 patients have been transferred to local ART sites.

Challenges

  • High turnover of the Trust Office medical stuff, Lack of QI Coaches at the following ART sites: Yahotyn Central Rayon Hospital, Vasylkiv Central Rayon Hospital, and Vyshgorod Central Rayon Hospital.
  • Lack of support from administration to QI Coaches and RIG members at the ART sites of Vasylkiv and Boryspil.
  • Patients do not want to be transferred to the domiciliary ART sites because of possible stigmatization.
  • Lack of fuel for biomaterial transporting, which is currently made once per 1-2 weeks and complicates HIV testing.
  • QI Coaches work part-time at the most sites.
  • Share of HTS among key populations by specialty physicians remains low.
  • Two ART sites (in Vorzel and Boryspil) are excluded from the project because of poor efficiency.

Next steps

  • Continue trainings on HCT for PHC practitioners, specialty physicians, and inpatient department doctors, and involve them to HIV screening.
  • Conduct a work meeting with chief physicians of the Vasylkiv and Borodyanka ART sites on hospital district structure and perspectives of the ART sites.
  • Prepare an order form the Kyiv Regional Healthcare Department to chief physicians of the future hospital districts on effective addressing HIV/AIDS in the districts and support of the ART sites.
  • Quality assurance  in the following areas: risk behavior screening, HIV screening, and improving adherence to treatment.
  • Due to the action plan, to continue mentoring visits to the RT sites and monitoring of the PDSA changes implementation.
Key Achievements 
  • Providing ARVs through the pharmacy network (Kyiv-Svyatoshyno district, Boyarka, Fastiv, Brovary).
  • Increased number of the RT sites, from 9 to 13. It is expected to start 25 sites more by the end of 2017.
  • Trust Offices in the cities of Myronivka, Obukhiv, and Rzhyshiv received additional premises. 
  • Fastiv Central Rayon Hospital provided the room for social worker of NGO.
  • All the ART sites developed local protocols with patient pathways.
  • Introduced the system of returning to care LTFU patients.
Challenges
  • Delays in the supply of rapid tests and ELISA testing systems in the region.
  • Difficulties with involving STI doctors and narcologists to HCT because of poor counselling skills and low motivation.
  • Excessive workload on ART site physicians.
  • Clients do not want to receive ART at the local site because of the possible stigmatization. 
  • Lack of standardized documents on referring at the different ART sites.  
  • Lack of NGOs in some rayons.
Next Steps
  • Engage specialty physicians to HCT more actively.
  • Engage NGO to cooperation with healthcare facilities.
  • Standardize the referral documentation. 

Key Achievements

  • Referring coupons, risk behavior screening algorithm, and other piloted changes were approved by the additional executive order of the Regional Healthcare Department.
  • Number of the healthcare facilities has increased by 27, out of which, 21 participate in the QI Collaborative.
  • Ongoing decentralizing of HIV services: by the end of September, 2016, 145 people have been transferred to the local ART sites.
  •  
  • Delivery of blood samples from the distant rayons is made only once per 1-2 weeks.
  • Staff of the most ART sites work part-time.
  • Lack of specially equipped premises to store drugs received from PEPFAR at the ART sites.
  • Poor skills of HCT among physicians at the new ART sites.
  • Numerous drop-outs because of high level of CD4.
  • Lack of NGOs in some rayons.

Next Steps

  • Training for 27 chief physicians of the ART sites on QI implementation and iproving initiation on ART.
  • Training for QI coaches of the new sites on running STMA.
  • Introduce social worker positions at the ART sites so to strengthen the continuum of the HIV services.
  • Quality assurance in the following areas: risk behavior screening, HIV testing, and improving adherence to treatment.

Key Achievements

  • Share of newly detected cases of the HIV has reached 8,1% and 28% among PWID.
  • Increased coverage of key populations with HTS: share of PWID increased from 9,9% in Jan-Mar, 2016, to 14,2% in Apr-June, 2016.
  • High HIV detection rate among the sexual partners (14,8%).
  • Increased number of PLHIV on ART: more than 1000 patients initiated on ART during Jan-June, 2016.
  • Over 45% of PLHIV and 65% of PLHIV/PWID receive ART at the local ART sites.
  • Effective cooperation with NGOs at the ART sites.

Challenges

  • Delays in the supply of rapid tests and ELISA testing systems in the region.
  • Poor counselling skills of healthcare practitioners in terms of status disclosure to sexual partners and their further HIV testing.
  • Low detection rate at the ART sites in the cities of Vorzel and Rzhyshiv,
  • Most of detected HIV cases are on the late clinical stages.
  • High level of professional burn-out among the local ART sites staff.
  • Lack of NGOs in some rayons.

Next Steps

  • Mentoring visits to the ART sites in Vorzel and Rzhyshiv for evaluation of their potential for detection of a new HIV cases.
  • Open new ART sites and involve them to the QI Collaborative.

 

 

HIV Screening, 2015-2017

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

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