Quality Improvement Collaborative in Kherson Region

QI Collaborative Change Package in the Kherson Region (12 ATR sites)

Key Achievements

• The QI Charter – 2020 is finalized.
• Signed MoU with the Regional Healthcare Department.
• The following QI changes are being implemented as a routine practice:
  • Administer all required lab tests over one patient visit to an ART site/Trust Office;
  • Extended working hours at ART sites/Trust Offices;
  • Return lab test results to an ART site/Trust Office through the Internet.
• Continued decentralization of HIV-services in the region: 20 ART sites opened (including TB and narcology hospitals), 11 of them capable of initiating on ART, and others dispense ART and provide treatment monitoring.
• Continued mentoring visits and online-counseling from QI mentors.

Challenges

• Medical Information System still not introduced.
• Delays in healthcare reform implementing.

Next Steps

• Trainings for medical nurses on treatment monitoring and adherence to ART.
• Sign the QI Charter.
• Continue implementing changes aimed at decreasing the linkage to care and treatment gaps.
• Continue mentoring visits to ART sites.

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

• 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

• Expand ART coverage to Dniprovsky rayon ART site since June, 2017.
• Introduce questionnaire on adherence to ART.
• Continue quality assurance of the HIV screening with rapid tests.
• Implement risk behavior screening at all 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 the rapid HIV test kits caused by delay in delivery resulted in low HIV detection rate.
• 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.