QI COLLABORATIVE OVERVIEW

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

In January, 2016, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Odesa Regional Healthcare Department. Between January and March, 2016, 41 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.

Regional QI Implementation Group (RIG): Regional Coordinator – Valentyna Bezpoyasna, QI Mentors – Vitaliy Filyuk, Liana Kovtunovych, Tetyana Rybak, Aram Bagdasaryan, Data Quality Mentor – Oleksandra Sadkova.
 

Site QI Coach
Odesa Regional AIDS Center Liana Kovtunovych
Odesa City AIDS Center, Trust Office №1 Yulia Berehovska
Odesa City AIDS Center, Trust Office №6 Victoria Ryzhkova
Odesa City AIDS Center, Trust Office №7 Volodymyr Dubynyak
Odesa City AIDS Center, Trust Office №9 Natalia Kolesnyk
Odesa City AIDS Center, Trust Office №12 Svitlana Sarandi
Odesa City AIDS Center, Trust Office №14 Lidiya Oleynyk
City clinic №2, Trust Office №2 Natalia Artemenko
City clinic №20, Trust Office №3 Igor Skuratovskyi
City clinic №10, Trust Office №4 Halyna Varkenyn
Branch of the Odesa City AIDS Center, Trust Office №5 Lyudmyla Shamrai
Branch of the Odesa City AIDS Center, Trust Office №10 Valentyna Dobroshtan
Branch of the Odesa City AIDS Center, Trust Office №11  Vadym Podhoretskyi
City clinic №8, Trust Office №8 Olena Klimovich
Ananiv Central Rayon Hospital Raisa Savalyuk
Artsyz Central Rayon Hospital Svitlana Savranska
Kominternove Central Rayon Hospital Tetyana Shevchenko
Bilyaiv Central Rayon Hospital Tetyana Lukyanyuk
Savran Central Rayon Hospital Lyudmyla Kropyvlyanska
Sarata Central Rayon Hospital Yevhen Nagnoynyi
Illichivsk Water Transport Hospital Maryna Alekseyeva
Tatarbunary Central Rayon Hospital Lyudmyla Kobylyanska
Rozdilna Central Rayon Hospital Natalia Svadkovska
Berezivka Central Rayon Hospital Lyubov Kinaryova
Mykolaiv Central Rayon Hospital Lyubov Zaytseva
Ismail rayon infectious disease hospital  Hanna Nikolayeva
Kiliya Central Rayon Hospital Olena Smyrna
Frunze Central Rayon Hospital Polina Berina
Velyka Mykhaylivka Central Rayon Hospital Oleksandr Tymchenko
Yuzhne City Hospital Natalia Tyshaninova
Krasnooknyanskyi Central Rayon Hospital Borys Smenyuk
Ovidiopol Central Rayon Hospital Olena Petrova
Tarutyno Central Rayon Hospital Lidiya Kuruch
Shyryaivo Central Rayon Hospital Olga Volkova
Odesa Regional TB Hospital Tetyana Kobalya
Odesa Regional TB Clinic Oksana Petrenko
Balta Central Rayon Hospital Mykola Polyakov
Bolgrad Central Rayon Hospital Tetyana Kara
Kodyma Central Rayon Hospital Valeriy Leongard
Odesa City AIDS Center, Trust Office №15 Hanna Kirmikchi
Podil District Hospital of Kotovsk Igor Venger
Podil City Hospital Valentyna Zakharova
Lyubashivka Central Rayon Hospital Svitlana Savytska
Reni Central Rayon Hospital Oleksandr Ivanov
Ivanivka Central Rayon Hospital Veronika Pekhteyeva
Ismail Central Rayon Hospital (clinic unit) Nadiya Tkachenko
Teplodar City Hospital  Anna Naumova
Regional TB Hospital of Bilgorod-Dnistrovskyi  Svitlana Ishenko

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO
«Strengthening HIV Services
Continuum at the ART Sites» 
CF «Alternatyva»		 «TB is Curable»
CFO «Razom za Zhyttya»		 «PWID Partner’s Health»
CF «Doroga do Domu»
Odesa  X X X
Balta X    
Berezivka     Х
Bilyaivka     Х
Bolgrad     Х
Kominternove      Х
Podolsk X    
Rozdilne X    
Chornomorsk X    

 

Milestones of the QI Collaborative in the Odesa Region

  • On June 30, 2015, the MOU between RESPOND, UCDC, and Odesa Regional AIDS Center was signed to improve HIV care and treatment using the QI methodology. 
  • On October 12-13, 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 Odesa region. 
  • A training sessions for 41 QI coaches were conducted on November 17-19 and 25-27, 2015.
  • The QI Charter was developed and signed on December 7, 2015. The QI Charter includes the gap analysis, changes to be tested, and improvement activities. 
  • The first regional QI learning session was conducted for 41 QI teams/100 people on April 5-6 and 7-8, 2016. 
  • On April 25-27, 2016, RIG and the local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • The second regional QI learning session was conducted for 41 QI teams/100 people on July 12-13 and 14-15, 2016.
  • Six computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • 124 healthcare practitioners took part in the advanced training on HCT at the Mechnikov National University of Odessa; at the same time 70 nurses were trained on HTS using rapid tests.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • The third regional QI learning session was conducted for 35 QI teams/103 people on December 13-14 and 15-16, 2016.
  • On March 27-29, 2017, RIG and members of three local QI teams took part in the third cross-regional QI learning session.
  • On April-May, 2017, 72 healthcare practitioners took part in the training on HTS with rapid tests supported by Marketplace.
  • The fourth (final) regional QI learning session was conducted for 36 QI teams/57 people on June 20-21, 2017.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (235 visits in the period of November 2015 – September 2017).

 

 

 

 

QI Collaborative Change Package in the Odesa Region (36 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

Х

22

36

 36

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

Х

28

36

 36

1.3. Make HTS info materials available for physicians and patients

–

28

–

 –

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

Х

–

–

 –

1.5. Provide escorting to patients by medical staff

–

28

–

 –

1.6. HTS for sexual partners of PLHIV

Х

23

–

 –

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

Х

–

–

 –

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

–

28

–

 –

1.9. Redistribute responsibilities on HTS among doctors and nurses

–

27

–

 –

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

Х

19

36

 36

2.3. More frequent transporting of biomaterial to the lab

Х

–

–

 –

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

–

28

36

 36

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

Х

28

–

 –

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

–

1

–

 –

2.8. Engage PHC physicians into care for PLHIV

–

25

–

 –
 

3. Treatment

3.1. Initiation and management of ART at ART site

Х

27

25

 36

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

Х

27

1

 1

3.3. Identification and treatment of PLHIV in discordant couples

–

28

–

 –

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

–

26

–

 –

4. Cross-cutting

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

Х

22

–

 –

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

Х

28

–

 –

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

Х

–

–

 –

4.4. Train physicians and nurses on HTS

Х

28

–

 –

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

–

25

–

 –

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

Х

28

–

 –

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

Х

–

–

 36

4.10. Introducing a position of social worker at health care facility/ART site

–

–

34

 –

Total Changes Implemented

16

20

6

 5

Х – number of QI sites implementing the change is undefined

Key Achievements

  • Achieved treatment targets set by PEPFAR.
  • QI Charter – 2020 is finalized and pending approval from the Regional Department of Health.
  • Medical Information System implemented on the regional level.
  • Prepared decree on engagement of the OB/GYN service into providing HTS with rapid HIV tests.
  • Rapid HIV test kits purchased from the regional budget (25,000 pcs).
  • Approved decree on HCT supervisions in the regional healthcare facilities.
  • Approved decree on quality assurance in HTS with rapid tests.
  • PHC facilities engaged into providing HTS with rapid tests.

Challenges 

  • Regional problems related to the ongoing healthcare reform.
  • Difficulties with creating the Odesa Regional Center for Diseases of Public Health Significance.
  • Understaffing of ART sites in the region.
  • Lack of the centralized procurements of the rapid HIV test kits.

Next Steps

  • Introduce HIV screening with rapid tests among women of reproductive age in the antenatal clinics and in case of a positive HIV test result of their sexual partners.
  • Introduce supervisions while conducting provider-initiated HTS.
  • Introduce the external quality assurance for HTS with rapid tests.

Key Achievements

  • HIV detection rate increased from 4% to 7,2% as of July 1, 2017.
  • Revision of the group of patients registered with AIDS service contributed to unregister of almost 2,000 people.
  • The number of ART patients increased by 11.000 people as of July 1, 2017.
  • Treatment targets set by PEPFAR achieved by 87%.
  • Rapid HIV test kits for rayons purchased from local budgets.

Challenges

  • Understaffing of rayon ART sites.
  • Excessive workload among physicians of some ART sites.
  • Lack of social worker positions at some ART sites.
  • Lack of unified patient e-register.

Next steps

  • Introduce dispensing ART by family doctors in four rayons of the Odesa region and four clinics of Odesa city.
  • Introduce additional physician and social worker positions where necessary.
  • Introduce Medical Information System in the region.
  • Finalize the regional QI Charter – 2020.

Key Achievements

  • Optimized transporting of blood samples and the centralized procurement of ELISA test kits at the expense of regional budget (for the following rayons: Reni, Kiliya, Izmail, Sarata, Tarutyno, Tatarbunary, Artsyz, Bolgrad, Balta, Lyubashivka and Ananiyiv, and the city of Izmail) expended HTS for key populations.
  • Rapid tests purchased at the expense of the PHC budgets (Belhorod-Dnistrovskyi, Ovidiopol, and Tarutyno rayons).
  • PHC practitioners engaged to HTS.
  • Increased access to monitoring of HTS effectiveness through optimized transporting of blood samples.
  • Increased coverage of previously LTFU patients with ART services through introducing of additional positions of social worker at the ART sites.

Challenges

  • Signing of the Paris Declaration in February, 2017 by the Head of the Odesa City Council requires amendments to the local and regional programs on HIV prevention.
  • Sustainability of the regional QI model after USAID RESPOND project ending.

Next steps

  • Develop regional QI Charter for 2017-2018.
  • Amend the regional program on HIV prevention (in section “Providing access to free HTS with rapid tests and increase in funding from local and regional budgets”) and elaborate the city program on HIV prevention.
  • Expand the PHC network providing HTS to key population (in the following cities: Artsyz, Balta, Berezovka, Velikomihaylovka, Zaharivka, Okny, Savran, Sarata, Tarutino, and Tatarbunary).
  • Implement the quality assurance system in using of the rapid HIV tests (development of the regulatory framework).
  • Conduct mentoring visits for quality assurance system in using of the rapid HIV tests in the PHC facilities.
  • Increase ART coverage in Odesa city.

Key Achievements

  • Specialty physicians engaged into HTS providing.
  • Social worker positions are introduced at the ART sites.
  • NGO “Alternativa” joined the intervention «Strengthening HIV Services Continuum at the ART Sites» at the five ART sites.
  • Management Information System (MIS) was started in Odesa.

Challenges

  • Lack of HTS by PHC physicians.

Next steps

  • To involve PHC physicians to HTS.
  • Introduce dispensing ART by PHC physicians at the two ART sites.
  • Introduce MIS in the regional lab and rayons.

Key Achievements

  • Physicians initiate on ART at the 40 ART sites.
  • All the registered patients undergo the necessary examinations before starting ART.
  • Approved local protocol on HIV treatment in the region.

Challenges

  • Staff turnover at the ART sites.
  • Low involvement of the rayon hospitals management in HIV prevention.
  •  Long waiting time for the results of the confirmatory lab tests. 

Next steps

  • Open nine new ART sites.
  • Introduce social worker positions at ART sites.
  • Introduce MIS in the regional lab and rayons.

Key Achievements

  • Specialty physicians engaged to HTS providing.
  • Two trainings for physicians and nurses on HCT and using of rapid tests.
  • Number of ART sites initiating on ART has increased to 37 (out of total number of 41)

Challenges

  • Shortage of the rapid HIV test kits, ELISA testing systems, and ARVs in the region.

Next steps

  • Using of mobile clinics to involve PLWID and their sexual partners to HIV testing.
  • Monthly analysis of the registered patients to identify patients to be initiated on ART according to the new protocol.
  • HTS for in-patients in the first day of hospital stay.
  • Measures to identify and link to care the seropositive group.

Key Achievements

  • Local protocol is prepared and adopted.
  • Local QI teams work at the all regional ART sites.
  • Together with the CF “Doroga do domu”, the grant is won for training of nurses to use rapid tests.
  • More active initiation on ART at the sites.

Challenges

  • Shortage of the rapid HIV test kits, ELISA testing systems, and ARVs in the region.
  • Difficulties with introducing MIS in the Odesa region. 

Next steps

  • Training of specialty physicians on HCT.
  • Providing a sufficient supply of ARVs.
  • Implementing PDSA plans.

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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