QI COLLABORATIVE OVERVIEW

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

In December, 2016, the QI Charter was signed between the City Healthcare Department and partners on Collaborative implementation. The Charter defines composition of the Regional QI Implementation Group, QI Mentors, and local QI teams. Between April and May, 2016, 4 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 (CF “Vertical” and Kyiv Brach of the PLHIV Network).

Regional QI Implementation Group (RIG): Regional Coordinator – Zhanna Antonenko, QI Mentor – Anna Anikeyeva, Data Quality Mentor – Natalya Buhayenko.
 

Site

QI Coach
Kyiv City Clinic №5, Svyatoshynskyi District ART Site  Volodymyr Boyko
Kyiv City Clinic №5, Desnyanskyi District ART Site  Olena Samsonova 
Kyiv City Clinic №5, Holosiyivskyi District ART Site  Tetyana Bondaruk
Kyiv City Clinic №5, Dniprovskyi District ART Site  Natalya Rudyuk

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO
Strengthening
HIV Services Continuum
at the ART Sites
Kyiv Regional Branch
of the PLHIV Network		 PLHIV Partner’s Health 
Kyiv Regional Branch
of the PLHIV Network		 PWID Partner’s Health 
“Vertical”
Charitable Foundation
Svyatoshynskyi
District ART Site		 X X X
Desnyanskyi District ART Site   X X
Holosiyivskyi District ART Site   X X
Dniprovskyi District ART Site   X X

 

Milestones of the QI Collaborative in Kyiv City

  • In June, 2015, the MOU between RESPOND, UCDC, and Kyiv Regional AIDS Center was signed to improve HIV care and treatment using the QI methodology. 
  • On October 6-7, 2015, a regional meeting was conducted for 40 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 Kyiv City.
  • A training session for 4 QI coaches was conducted on December 14-16, 2015.
  • The QI Charter was developed and signed on December 29, 2015. The QI Charter includes the gap analysis, changes to be tested, and improvement activities. 
  • The first regional QI learning session was conducted for 4 QI teams of Kyiv City and 13 QI teams of the Kyiv region (total of 64 people) on April 19-20, 2016. 
  • On April 25-27, 2016, RIG and 4 local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • On April 6, 2016, Kyiv City joined the Fast Track City initiative and signed the Paris declaration on commitment to Ending AIDS.
  • The second regional QI learning session (joint for Kyiv City and Kyiv region) was conducted for 17 QI teams/83 people on July 27-28, 2016.
  • Two computers were purchased for Svyatoshynskyi and Dniprovskyi ART sites for running the Simplified Treatment Management Application (STMA) database.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • On September 19-21, 2016, RIG and representatives of local QI teams participated in the second cross-regional learning session in Kyiv.
  • The third regional QI learning session was conducted for 4 teams/35 people on December 22-23, 2016.
  • On March 28-29, 2017, RIG and representatives of local QI teams took part in the third cross-regional learning session in Kyiv.
  • The forth regional QI learning session was conducted for 4 QI teams/46 people on June 22-23, 2017
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (69 in the period of December, 2015 – June, 2017).

 

 

 

 

QI Collaborative Change Package in Kyiv City (4 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

_

4

_

 _

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

Х

4

4

 4

1.3. Make HTS info materials available for physicians and patients

_

4

_

 _

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

_

4

3

 1

1.5. Provide escorting to patients by medical staff

Х

–

–

 _

1.6. HTS for sexual partners of PLHIV

–

4

–

 _

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

_

4

4

 4

2. Linkage and enrollment 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

_

4

_

 4

2.3. Transport biomaterial to the lab more frequently

Х

4

_

 _

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

–

4

–

 _

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

_

4

_

 _

2.10 Engage infectious diseases specialist into medical care and treatment of PLHIV

_

_

4

 3
 

3. Treatment

3.1. Initiate and manage ART at ART site

_

4

_

 _

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

_

4

_

 _

3.3. Identify and treat PLHIV in discordant couples (also see 1.8)

_

4

_

 _

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

_

4

_

 _

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

_

4

_

 _

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

_

_

1

 1

4. Cross-cutting

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

Х

4

_

 _

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

Х

4

_

 _

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

_

Х

Х

 _

4.4. Train physicians and nurses on HTS

Х

4

–

 _

4.5. Train physicians on ART

–

4

Х

 _

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

_

4

_

 _

4.7. Purchase of rapid tests from local/rayon budgets

_

Х

_

 _

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

_

4

_

 _

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

_

4

_

 _

Total Changes Implemented

5

24

6

6

Х – number of QI sites implementing the change is undefined

Key Achievements

  • HTS are available at all healthcare levels in all the Kyiv districts.
  • PHC facilities have the widest network providing HTS.
  • Four Kyiv districts engaged into QI Collaborative make 71% of all HIV tests in the city.

Challenges

  • Significant number of patients screened positive for HIV in PHC facilities has already been registered with AIDS service.
  • Poor HIV detection rate at PHC facilities.

Next Steps

  • Continue providing HTS at all healthcare levels.
  • More thorough selecting of patients for HTS.
  • Continue QI mentoring visits to support introducing HTS in healthcare facilities.
 

Key Achievements

  • HTS with rapid tests is implemented in all medical facilitiesengage into QI Collaborative in Kyiv city.
  • HTS coverage increased 2,5 times in comparison with the period of Jan-Mar, 2017 (from 1,165 to 3,064 people).

Challenges

  • Understaffing of PHC facilities and infectious disease facilities in Kyiv city.
  • Low detection rate of HTS by PHC providers and specialty physicians.
  • Poor level of knowledge and experience in HTS providing among specialty and PHC physicians.
  • Excessive workload on a Trust Office staff.

Next steps

  • Continue implementation of the QI changes.
  • Scale up providing HTS with rapid tests by PHC and specialty physicians.
  • Scale up successful QI changes to other districts of Kyiv city.

Key Achievements

  • Increased ELISA usage in the Kyiv healthcare facilities participating in the QI Collaborative.
  • Increased coverage by HIV screening by specialty physicians on clinical and epidemiological indications for risk behavior.
  • Increased PLHIV detection and registration with AIDS service in Kyiv city resulted from the districts participating in the QI Collaborative.
  • Decreased share of late HIV detection cases among people registered with AIDS service.
  • Increased ART coverage among PLHIV in active follow-up.
  • Implemented algorithm of HIV screening with rapid tests and ELISA.
  • Heads of the Rayon Healthcare Departments joined the work of the QI teams.

Challenges

  • Delays in supply of the rapid HIV test kits in healthcare facilities.
  • Physicians poorly covered of with trainings on HTS with rapid tests.
  • Lack of skills and knowledge on QI methodology among new members of the QI teams.

Next steps

  • Expand the QI local teams’ staff.
  • Supply healthcare facilities with the rapid HIV test kits.
  • Inform healthcare practitioners on using rapid tests in HTS.
  • Approve composition of the local QI teams and their regulations by the Healthcare Department.
  • Ensure monitoring of PLHIV coverage with medical supervision depending on location of detection (ART site, healthcare facility, and NGO) so to identify the gaps and possible improvement changes.
  • Implement activities on raising awareness among pilot district population on HIV infection (clinical indications and risk factors).
  • Study opportunities for advanced training on quality improvement for the new members of the QI local teams at the Bogomolets Medical University.

Key Achievements 

  • Increased number of patients in active follow-up due to implementation of the reminder measures,
  • Increased number of patients initiated on ART on the Kyiv city ART sites.
  • Increased HIV detection rate by specialty physicians in Kyiv city.
  • All the lab tests required for registration with AIDS service are made in one patient visit to ART site.
  • Optimized delivery of blood samples to the City AIDS Center for HIV testing.

Challenges

  • Overload at the ART sites leads to lower quality and efficiency of work.
  • Poor quality of HIV testing by specialty physicians.
  • Low motivation of some specialists to providing HTS.

Next Steps

  • Expand the local QI teams by engaging PHC and specialty physicians.
  • Include representatives of the rayon healthcare departments to the local QI teams.
  • HIV testing in first three days of hospitalization.

Key Achievements

  • Patient registration time decreased to 1.5 days.
  • Implemented policy of a "green corridor" for PLWID / PLHIV who undergo examination for registration with AIDS service.

Challenges

  • Overload at the ART sites leads to lower quality and efficiency of work. 
  • Low motivation of some specialists to doing HTS. ​

Next Steps

  • Engage specialty physicians into work of the local QI teams.
  • Engage NGOs into active cooperation with healthcare facilities; optimize work of social workers at ART sites.
  • Approve local protocols and executive orders aimed at decentralizing of HIV-services and increased coverage by the ART services.

Key Achievements

  • Four coordinating meeting conducted in pilot Kyiv districts in March-May 2016, aimed to scale-up the QI methodology and engage specialty physicians into providing HCT and referring to ART sites for HTS.
  • Drafted executive order on local protocols.

Challenges

  • Overload at the ART sites leads to lower quality and efficiency of work. 
  • Low level of HIV testing by specialty physicians.
  • Low motivation of some specialists to doing HTS. 

Next Steps

  • Engage specialty physicians into work of the local QI teams.
  • Engage NGOs into active cooperation with healthcare facilities; optimize work of social workers at ART sites.
  • Approve local protocols and executive orders aimed at decentralizing of HIV-services and increased coverage by the ART services.

Key Achievements

  • All existing ART sites have developed local protocols with described patient pathways.
  • Decentralizing of HIV-services has been started (including training of rayon infectious disease doctors on ART basics).
  • Improved cooperation between the local QI teams and NGOs in detecting new cases of HIV among PLWID and linkage to care for PLHIV. In January-June, 2016, the detection rate among PLWID is 26,4%.
  • Developed referring card to ART sites to be used by the specialty physicians.
  • Daily delivery of blood samples from healthcare facilities to ART sites for HIV testing.

Challenges

  • Excessive work load on ART site physicians, patient-to-physician ratio is 600-1,500 patients.
  • Lack of conditions for the efficient work of social workers at the ART sites on improving adherence and social support.​

Next Steps

  • Improve the work of the local QI sites in involving of the specialty physicians to HCT.
  • Plan to expand the ART onto four pilot ART sites.
    ​

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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