Download - Improving Care for Patients Living with HIV/ fileImproving Care for Patients Living with HIV/AIDS M. Rashad Massoud, ... The key issue in health care quality. 2. ... quality care is

1

Improving Care for Patients Living with

HIV/AIDS

M. Rashad Massoud, MD, MPH, FACP

Director, USAID Applying Science to Strengthen and Improve Systems Project

Senior Vice President, Quality & Performance Institute

University Research Co., LLC – Center for Human Services

Bruce Agins, MD, MPH

Director, HEALTHQUAL International

New York State Department of Health

USAID Applying Science to Strengthen and Improve Systems

Objectives

After this session, participants will be able to articulate:

1. The key issue in health care quality.

2. The fundamentals underlying the science of

improvement.

3. The link between evidence-based medicine and

organization of care delivery to produce better

outcomes.

4. How improvement enhances efficiency of care

delivery.

5. Examples of successful improvements in USAID OHA

programs from different countries.

2


Session Outline

3

Topic Presenter

What do we mean by

quality care?

Defining quality care

Vignette

Conclusion

Rashad

Bruce

What is the key issue in

quality of care?

Presentation Rashad

How do we improve

care?

Overview of the science of

improvement

Fundamental concept

underlying improvement

Principles of improvement

Bruce

Examples of improving

HIV/AIDS care

Project and national level

improvements

Rashad

Bruce

4

What do we Mean by Quality Health Care?


Definition of Health Care Quality

“ The degree to which health services for

individuals and populations increase the

likelihood of desired health outcomes and

are consistent with current professional

knowledge “

5

Institute of Medicine, USA


What is Quality Care?

Quality care is what happens at all the points of

service along the continuum of care, and high

quality care is a function of the system's ability

to produce care that will address the client's

needs in an effective, responsive and respectful

manner…

— David Nicholas

6


Aims for Quality Health Care System

• Safety

• Effectiveness

• Patient Centeredness

• Timeliness

• Efficiency

• Equity

7

Institute of Medicine, USA

Mediator between blocks and outcomes

QUALITY MANAGEMENT

S A F E T Y

LICENSURE CERTIFICATION

QUALITY CONTROL

PATIENTS’ RIGHTS

Quality Improvement

“the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”

Batalden & Davidoff. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care 2007; 16: 2-3. doi: 10.1136/qshc.2006.022046

11

The key issue of quality in health care

USAID Applying Science to Strengthen and Improve Systems 12 Source: World Health Organization Source: United Nations 2013

Health MDGs Scorecard

GOALS AND

TARGETS

Africa Asia

Oceania

Latin

America

& the

Caribbean

Caucasus &

Central

Asia Northern Sub-

Saharan Eastern

South-

Eastern Southern Western


What is the problem: WHO

“The reality is straightforward. The power

of existing interventions is not matched by

the power of health systems to deliver them

to those in greatest need, in a comprehensive

way, and at an adequate scale.”

—Margaret Chan

Director General

World Health Organization

13

McGlynn et al. NEJM 2003. “The quality of health care delivered to adults in the U.S.”

• 439 indicators of clinical quality of care

• 30 acute and chronic conditions, plus

prevention

• Medical records for 6712 patients

• Participants received 54.9% of scientifically

indicated care (Acute: 53.5%; Chronic: 56.1%;

Preventive: 54.9%)

• Conclusion: The “defect rate” in the technical

quality of American health care is approximately

45%

14

USAID Applying Science to Strengthen and Improve Systems 15

“… Between the health

care we have and the

care we can have lies

not only a gap, but a

chasm…”

“… The problems

come from poor

systems – not bad

people…”

The Issue of Quality in Health Care


What is the problem: World Bank

“The enormous investments that have been made in

global health should have led to what we might have

called a science of implementation and execution…

…We have just not focused on the enormous

complexity of delivering health care in a way that

keeps people healthy ”

—Jim Kim

President, World Bank

16

17

How do we improve health care?


Improvement Principles & Frameworks

Fundamental Concept of Improvement:

“Every system is perfectly designed to achieve exactly

the results it achieves”

Principles of Improvement:

– Understanding work in terms of processes and

systems

– Developing solutions by teams of health care

providers and patients

– Focusing on patient needs

– Testing and measuring effects of changes

– Shared learning

18

What is a System? (IOM)

System: a set of interdependent elements working to

achieve a common aim. The elements may be both

human and nonhuman (eg, equipment, technologies).

Appreciation of a System

20 API- 2014

Systems Thinking

Source: Donabedian, A. Explorations in Quality Assessment and Monitoring Vol. 1.

The Definition of Quality and Approaches to Its Assessment . Ann Arbor, MI: Health

Administration Press, 1980. Adapted by USDHHS, HRSA.

Fundamental Concept of Improvement

“Every system is perfectly designed to achieve

exactly the results it achieves.”

23

Shewhart Charts

The Shewhart chart is a statistical tool used to distinguish between variation in a measure due to common causes and variation due to special causes

Note: A stable process does not say anything about the

quality of the process

HC Data Guide, p. 113 24

0

10

20

30

40

50

60

70

80

90

100

Jan-09 May Sep Dec Jan-10 May Sep Dec Jan-11 May Sep Dec

Pe

rfo

rman

ce R

ate

(%

) System Retention Rate

0

10

20

30

40

50

60

70

80

90

100

Jan-09 May Sep Dec Jan-10 May Sep Dec Jan-11 May Sep Dec

Pe

rfo

rman

ce R

ate

(%

)

System Retention Rate

29

0

20

40

60

80

100

Jan-09 May Sep Dec Jan-10 May Sep Dec Jan-11 May Sep Dec Jan-12 May Sep Dec Jan-13

Pe

rfo

rman

ce R

ate

(%

)

System Retention Rate

0

10

20

30

40

50

60

70

80

90

100

Perf

orm

an

ce R

ate

(%

)

New System Retention Rate

Understanding Variation

31

HC Data Improvement Guide

#

of

Ne

ed

les

tic

ks

Employee Needlesticksc c ha r t

UCL = 12.60

Mean = 5.54

New Needles Test

1-05 3-05 5-05 7-05 9-05 11-05 1-06 3-06 5-06 7-06 9-06 11-06 1-07 2-07

0

5

10

15

20

32

QI Principles



exactly the results it achieves”


– Developing solutions by teams of providers and

patients

33

Why Teamwork?

What does the process really look like?

QI Projects: CD4 Monitoring

Challenges and Barriers

• Provider education • Ensure test done at first visit or in advance • Accompanying patient to the lab • Record test in clinic and health passport • Develop satellite testing sites • Transportation services by NGOs • Look at process flow of transport of

specimens and tracking of results • Involve pharmacist in monitoring for date of

test

Improvement Strategies

• Transport of specimens

• Return for monitoring

• Laboratory equipment access

36

CASE STUDY: Coordination of Team Activities at TASO Mbale Medical Officer: coordinate clinics & give health talks Triage Nurse: identifies clients for CD4 screening, Lab Technician: takes samples and release timely results, Data Officer: generates reports & ensures efficient filing system Front Desk Officer: streamline flow of clients Counselor: identifies clients, coordinates group sessions, educates clients about the importance of CD4 screening, Field Officer: links clients & streamlines field appointments for CD4 re-screening

What is robust process improvement?

1. Identifying root causes of a problem

2. Measuring the importance of each cause

3. Proving the effectiveness of the solutions

4. Deploying programs to ensure sustainability of the

improvements

Chassin and Loeb. Health Affairs, 30, no.4 (2011):559-568

The Ongoing Quality Improvement Journey: Next Stop, High Reliability

QI: Retention (Erie County Medical Center)

Identifying Root Causes & Establishing the Importance of Each Cause

REASON #

Patients

Mean

VL

Medically stable; Feel well 13 21

Job conflict with

appointment

6 258

Fear if disclosure if seen at

clinic

1 20

Ongoing alcohol/substance

use

14 32194

Mental health issues 8 15044

Lack of

understanding/engagement

13 27436

Transportation 1 415211

Housing instability 1 20

Also receiving care

elsewhere

1 20

Cost (coverage) 1 272

Refuses treatment 1 4942

Hospitalized 0

Incarcerated then released 2 2210

Deploying Programs to Ensure Sustainability of the Process

QI Principles





– Focusing on patient needs

39

Dimensions of Quality

Technical Quality

Provider

Perception of

Quality of HIV

Care

Experience Quality

Consumer

Perception of Quality

of HIV Care

Leonard Berry, Texas A&M University, IHI conference 2001

• Consumer advisory board

• Focus groups

• Exit interviews

• Participation on quality teams

• Reviewing data

• Setting priorities for improvement

• Patients serving on QM Committee

How to involve consumers?

QI Principles





– Testing and measuring effects of changes

42

TESTING CHANGES

What are we trying

to accomplish?

How will we know that a

change is an improvement?

What change can we make that

will result in improvement?

Act Plan

Study Do

Model for Improvement

Model

for

Improvement

QI Principles





– Peer learning

45

Regional QI Groups (learning networks; learning communities)

• Regional groups promote sharing of

improvements and strategies

• Local issues drive priorities

• Coordination of care enhanced

• Facilitates involvement of other

stakeholders:

– State….city….county….

FHI Quality Assurance Quality

Improvement guiding principles

Develop

standardsImplement

standards

Measure

performance

against

standards

Identify quality gaps

and performance

issues

Address

issues

QA

Identify the

improvement

goal/objectives

QIDevelop the

improvement

measurement

system

Develop ideas

for changes

Test system

changes

Sheila

Leatherman

ISQUA

GHAHA 2013

WHY IS THERE CONFUSION ABOUT QI?

Improvement Models

• Shewhart (SPC/PDCA)

• Deming – CQI

• Model for Improvement (PDSA)

• Six Sigma

• Lean

• 5S

• Kaizen

• Total quality management

Leatherman, Ferris, Berwick, Omaswa and Crisp. The Role of Quality Improvement in Strengthening Health Systems in Developing Countries. Int J Qual Healthcare 2010; 22: 23-43.

DEFINITION: Rather than attempt to re-define the meaning of quality in a global context, the group developed a shared understanding of the term ‘quality improvement’ as both a philosophy and a family of discrete technical and managerial methods.

Methods: Process investigation and analysis

Operations research

Teamwork

Assessment and improvement

Optimal use of measurement and statistics in daily work

Benchmarking

Participative management techniques

Methods are focused on patients and their families and enable providers and organizations to continuously learn and to change the systems in which they work to achieve improved health outcomes for those they serve.

Systems Thinking

Source: Donabedian, A. Explorations in Quality Assessment and Monitoring Vol. 1.

The Definition of Quality and Approaches to Its Assessment . Ann Arbor, MI: Health

Administration Press, 1980. Adapted by USDHHS, HRSA.

The Challenges That Lie Ahead

• The “deep reach” to the most marginalized, vulnerable and

remote populations.

• The use of real-time data to inform strategies for change at

the local level.

• The engagement of the providers and consumers to work

together to achieve improvement goals in their community.

• Undeveloped communication/knowledge management

strategies.

• Integration of HIV improvement work into national health

sector quality management programs.

– “Quality improvement requires that providers and policymakers identify

their own weaknesses and address them directly”. -Scott, Jha. NEJM 2014;

371: 5

• Sustainability of improvement once initial gains are

achieved.

Within Our Reach

• Biomedical interventions are now available to achieve both health outcomes and zero transmission.

• Improvement methods are known and have spread to provider communities.

• Implementation of guidelines is possible throughout the healthcare sector.

• We know and so we now must apply…


Employee Engagement (…or lack thereof)

59

Examples of Improving Health Care


% of clients whose nutritional status is assessed using mid-upper arm circumference (MUAC)

0

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w-2

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w-1

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%

0

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w-2

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%

0

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%

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%

0

10

20

30

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50

60

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90

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%

Train expert

clients to do

MUAC

Assign a staff person to do

MUAC after registration

A sustained change Tell everyone to do MUAC

a non-sustained change

Nutrition

training Informed of

external visit

Delivery of

commodities


Uganda: Applying Chronic Care Model to improve coverage, retention, and clinical outcomes

61

Examples of

Changes

Used SM

progress tool

and tally sheets

to record Pt SM

progress

Introduced a

VHT referral

form to give to

patients when

sent to a facility

Each patient

enrolled is

introduced to a

VHT in

catchment area

SM groups

formed

0

1000

2000

3000

4000

5000

6000

7000

8000

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Feb

-11

Mar

-11

Ap

r-1

1

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Coverage, Retention, and Clinical Outcomes at 5 sites - Buikwe District Oct 2010 - May 2013

# of clients eligible to be enrolled on ART # of clients ever enrolled on ART

# of expected ART clients # of active ART clients

# of ART clients with good clinical outcome

Coverage Gap44%

1%

Retention Gap49%

23%

Wellness Gap53%

9%

End of intervention

16%

25%

14%


Uganda: Performance of Safe Male Circumcision sites on MOH quality standards (Baseline 2013 vs Jan 2014)

62

Health Unit

IP

Supportin

g Site

District

Manageme

nt systems

Supplies,

equipment

&

environme

nt

Registratio

n group

education

and IEC

Individual

counseling

& HIV

testing

Male

circumcisi

on surgical

procedure

Monitoring

&

evaluation

Infection

prevention

Manageme

nt systems

Supplies,

equipment

&

environme

nt

Registratio

n group

education

and IEC

Individual

counseling

& HIV

testing

Male

circumcisi

on surgical

procedure

Monitoring

&

evaluation

Infection

prevention

1 30 50 0 33 92 70 83 67 100 91 86 91

2 20 33 0 7 67 80 67 75 87 92

3 40 83 0 14 77 80 67 100 93 100

4 30 50 0 18 82 90 83 83 83 80 92 100

5 20 33 0 14 80 80 67 83 100 80 86 85

6 10 50 7 70 90 83 100 100 100 93 93

7 40 50 50 75 40 70 83 67 83 82 86 89

8 50 50 25 14 77 90 100 83 100 90 86 85

9 60 50 83 39 64 29 69 90 100 100 82 100 100 100

10 20 50 50 0 33 90 100 100 83 100 92 93

11 33 25 0 0 64 80 100 100 80 80 77 75

12 25 33 0 70 100 83 100 80 83 100 92

13 60 67 75 83 81 14 38 90 67 83 100 100 86 100

14 70 50 25 50 16 100 83 100 100 100 93 100

15 60 33 25 50 46 100 84 67 100 82 67 100

16 30 67 100 14 58 100 100 100 100 100 100 100

17 40 83 75 100 100 14 58 90 83 100 100 100 100 92

18 70 67 100 67 100 69 75 100 67 100 100 100 100 75

19 40 50 0 21 46 100 83 83 100 97 100 100

20 60 50 0 21 92 100 83 83 83 85 93 85

21 70 50 0 21 46 90 67 83 94 77 100 76

22 80 83 100 93 100 90 100 100 100 100 100 100

23 70 100 100 100 100 93 100 90 84 100 100 100 100 100

24 70 100 100 100 100 93 100 90 100 100 100 100 93 100

25 60 50 100 46 100 90 83 50 83 82 50 77

26 60 33 50 15 62 90 67 84 100 85 79 92

27 40 83 75 100 100 75 92 90 84 100 100 91 86 100

28 20 50 78 15 38 90 75 50 94 87 93 70

29 22 67 67 47 29 85 80 67 67 83 80 93 82

30 40 67 38 62 90 67 83 100 91 93 82

Baseline results As of January 2014


Tanzania: HIV-infected pregnant women started on or receiving ARVs (AIMGAPS)

63

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14

% HIV-infected pregnant women started on or receiving ART (treatment) or ARV prophylaxis in 11 sites in Iringa Region, Tanzania January, 2011 – February, 2014

0

100

200

300

400

Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14

Denominator: Total # HIV-infected pregnant women who are eligible for ART and ARV prophylaxis

Changes tested:

1. Storing ARV at RCH 2. Documentation at time of service provision

3. Keeping PMTCT care register at follow-up client care point. 4. Keeping constant stock levels of ARTs at RCH

May-11: LS 1—

Providers trained

on QI principles, QI

teams formed.

Aug-11: Adopted WHO 2010

guidelines. Change in guidelines

increased # of clients eligible for ARVs

Nov-11:

Increased stocks

of ARVs at RCH

to meet demand

Mar-12: Shortage of ARVs

Oct-13: All AIMGAPS

sites transitioned from

WHO treatment

Option A to Option B+


Study 27 Improvement Collaborative Improvements in 12 Countries: Scope and Content

Topic areas MNCH

FP

HIV/AIDS

Tuberculosis

Malaria

PHC

Countries (12)

Collaboratives (27) Benin (3)

Bolivia (1)

Ecuador (2)

Guatemala (2)

Honduras (1)

Nicaragua (1)

Niger (3)

Russia (6)

Rwanda (3)

Tanzania (3)

Uganda (1)

Vietnam (1)

Indicators and

Time series charts

135 time series charts

representing 81 indicators


How were the 135 time series charts analyzed?

Number of months to

reach ≥ 80%:

15 months

Absolute

improvement

from

baseline:

1496 =

82%

Relative

increase

from

baseline:

96/14=580%

Reached ≥ 80%? Yes

Interval

(range) at

stabilized

level of

quality:

75-97 = 22

Number of

consecutive

months that

indicator values

stayed over 80%:

25 months

Reached ≥90%? Yes

Number of months to

reach ≥90%:

39 months


Results of 135 Time Series Charts from 27

Collaborative Improvements in 12 Countries

• Performance improved regardless of baselines:

– 88% teams reached 80% compliance or above

– 76% teams reached 90% compliance or above

• Results were achieved relatively rapidly:

– For indicators starting at < 50%, teams reached 80%

compliance in 13 months

– For indicators starting at > 50%, teams reached 80%

compliance in 6 months

• Collaborative improvement can produce

sustained gains in performance

– 80% performance was sustained on average for 13.4

months out of 19.5 months of data collection

66


Idées pour surmonter les

Barrières

ANALYSES SYSTEMES

Implémentation

Improvement of ART enrollment through improvement of quality of service Experience of Hopital Universitaire de la Paix Derival Raymonde, MD; Bogart Mie Johanne, Nurse; Maisonneuve Yvette, Nurse; Isaac Daniel, SW; Aristile William,Data

Clerk; Auguste Marie Carmen , Nurse; Jenny X; Clerrier Nadege

BACKGROUND -Rationale of the ART Enrollment project All medically eligible HIV positive patients should be enrolled on ART. ART enrollment will reduce the morbidity and mortality rate and improve the patients’ quality of life.

From our Electronic Medical Record, data of HIVQUAL report from July to Dec 10 revealed that only 82 among 331 medically eligible patients (24.8%) had benefited from ART enrollment.

0102030405060708090

100

Co

nti

nu

ity

AR

V

Mo

nit

CD

4

AR

V E

nro

l

Px

TMS

Ad

her

ence

TB S

cren

nin

g

Nu

trit

ion

ass

ess

Fam

ily P

lan

nin

g

PM

TCT

Imm

un

isat

ion

%

HIVQUAL report jul-dec 10

A multidisciplinary team was created by the Quality Management Committee to assess the problem, led by 1 MD , with 3 nurses, 1 data cler, 1 field agent and 1 patient. AIM STATEMENT: To improve ART enrollment from 24.8% to 45% over six months.

IMPROVEMENT CHANGES & INTERVENTIONS

First Strategy-Patient Awareness: Psychologist & SW counsel patients about importance of visits; Clerk highlights new patients in register Second Strategy - Reduction in Pre-ART period: Weekly visits required for patients until ART Enrollment. Third strategy –Enrollment Acceleration: Increase number of new enrollees with new verifcation process by data clerk. Participation in post-test clubs.

Reduction of pre-ART wait and increasing patient contact had the greatest impact

LESSONS LEARNED: -Coordination between psychosocial and medical units was key to success of ART enrollment. -Need sufficient time for committee meetings to select patients for enrollment from pre-ART list. -Staffing levels require more than one psychologist to help patients accept treatment and address mental health problems.

HAITI: The Power of an EMR (iSante) but Why aren’t patients getting ART?

75.5

29.6

46.6

57.3

27.7 23.9

83.7

4.4

38.4

1.2

74.8

24.3

40.9

85.888.1

79.2

74

32.5

54.6

41.2

41

42

33

29

30

67

10

66

6

30

90

37

62

11

08

7

66

82

28

9

32

7

20

88

4

48

85

62

98

27

72

7

13

15

3

49

22

30

22

1

15

45

1

79

3

12

92

0

10

20

30

40

50

60

70

80

90

100

CC ARV CD4 ARV TMS Adh TB Nutrition PF PTME Vaccin

%

Indicators

DDB juin--08 DDS juin 11 # de cas juin 08 # de cas juin 11

LIMITATIONS SOLUTIONS

•Stringent requirements applied

for ARV Eligibility

•4 Adherence sessions

•Buddy companion

•Identification of patient house

•Refresher training for psycho-social staff

•Technical Assistance to “Selection

Committee”

• Focus on systems that get patients services

•Lack of implementation of

guidelines for treatment initiation

•Increase awareness about groups that could

be put on Rx without CD4

•Limitations with CD4 •Progressive phaseout of current equipment

Roll out of Facscount and regional hubs.

•Dedicate more man power at sites when

manual system is in use

•Logistics of Drugs for site

upgrade and launching of new

sites

•Better coordination between service

implementers and SCMS for site upgrade

and launching of new sites

*In 2011, Haiti data were retrospectively stratified into adult and pediatric (< 15 years old) data for all but nine clinics. Those nine clinics are not

included in the aggregate results for the first six review periods. Beginning in the 7th review period, Jan – Jun 11, all data from all clinics are stratified

and included in the aggregate results.

Haiti ARV Therapy Percentage of adult patients eligible for ART who were enrolled in ART during the six-month review period

NAMIBIA: A Tale of Improving Food Security

Initially lack of screening tool in the HIV patient care booklet Poor documentation Lack of proper referral mechanism No support groups address food security Staff turnover and high workload High national unemployed rate/poverty Alcohol abuse

INTERVENTIONS

⁻Training of HCWs on importance of issue & measuring --Health education to patients/clients (specifically on alcohol abuse ) ⁻Devise basic, simple food security screening tools ⁻Improve documentation system ⁻Reorganize patient flow to streamline assessment ⁻Identification of focal person to conduct assessments ⁻Referrals, documentation/follow-up of patients needing food supplementation to NGOs ⁻Arrange effective referral system ⁻Introduction of NACS (Nutritional Assessment Counseling and Support) programme Nationwide. ⁻Strengthen integration of social workers into care teams to assess food security ⁻Initiation of nutrition gardens ⁻Soup kitchen corners (nutritional education)

Download - Improving Care for Patients Living with HIV/ fileImproving Care for Patients Living with HIV/AIDS M. Rashad Massoud, ... The key issue in health care quality. 2. ... quality care is

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