Quality improvement in HIV treatment services in Rwanda ( using the existing electronic recording and reporting systems), and the transition of these services.

Quality improvement in HIV treatment services in Rwanda ( using the existing electronic recording and reporting systems), and the transition of these services from international partners to MOH.

 Endris Mohammed1,2, Byringiro Vianney2, Sabin Nsanzimana2

1: Rwanda Family Health Project

2: Rwanda Bio Medical Center (RBC)

IAS 2013, Kuala lumpur, Malaysia July 1, 2013

Outline

Country profile Track 1.0 transition in Rwanda RBC/IHDPC/HIV division QI program overview Rwanda electronic recording and reporting

system QI program strategies-real time accessible

health data driven Selected results Conclusions Lessons Learned & recommendations

Rwanda at a Glance

• Total Population: approx. 11 million

• HIV Prevalence: 3% (2010 DHS)

• Total No. of patients on ART by the end of April 2013: 118,657 (> 94% of those in need)

• Total number of health facilities: 510• 486 PMTCT sites• 490 VCT sites• 458 ART sites

By the end of April 2013

Track 1.0 Transition in Rwanda

• CDC-Rwanda began transitioning financial and technical responsibilities for HIV clinical services at 76 Health Facilities from international NGOs to MoH-Rwanda in 2010

• Transition completed by February 2012

• Financial and clinical performance of transitioned sites monitored every 6 months

• MOH-Rwanda and HEALTHQUAL developed site-level QI program in March 2011 to help maintain the quality of clinical care

May Jun

eJuly

Aug.Sept Oct

. Nov.Dec.

Jan.Feb. March

April MayJune July Aug.

Sept.

2010 2011

Cohort 1 Transition*18 Sites

Cohort 2 Transition6 Sites

Cohort 3 Transition26 Sites

C1 Baseline C1 6- Month FU C1 12-Month FU

C2 Baseline C2 6-Month FU

C3 Baseline

Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda

C3 6-Month FU

Cohort 3.5 Transition**20 Sites

C3.5 Baseline

**The financial transition for Cohort 3.5 sites will occur in March 2011

C3.5 6-Month FU*The Cohort 1 transition occurred in March 2010

Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda

Oct. Nov

.Dec.

Jan.Feb. Marc

h AprilMay June

July Aug.Sept.

Oct.Nov.

Dec.Jan.

Feb.

2011 2012

C1 18-month FU C1 24- Month FU

C2 12-Month FU C2 18-Month FU

C3 12-Month FU

C2 24-Month FU

Cohort 4 Transition6 Sites

C4 Baseline C4 6-Month FU

C3 18-Month FU

2013

C3.5 12-Month FU C3.5 18-Month FU

March

C4 12-Month FU

C3 24-Month FU

C3.5 24-Month FU

List of clinical indicators used in the transition assessment

1. The proportion of HIV+ pregnant women eligible for triple therapy prophylaxis who received triple therapy prophylaxis

2. The proportion of HIV+ pregnant women eligible for triple therapy for life who received triple therapy for life

3. Proportion of partners of pregnant women presenting for their first antenatal care consultation who are tested for HIV

4. Proportion of infants born to HIV+ mothers who received ART prophylaxis at birth

5. Proportion of infants born to HIV+ mothers that have PCR at the age of 6 weeks

6. Proportion of currently enrolled patients on Pre-ART and ART who are on CTX

List of clinical indicators used in the transition assessment conti…

1. The proportion of ART patients who are still on treatment 12 months after initiation

2. The proportion of patients newly enrolled in HIV services who were screened for TB

3. Number of patients newly initiating on ART during the reporting period a. Pediatric patients b. Adult patients

4. Number of patients currently on ART at the end of the reporting period

5. Proportion of patients who received ARVs for 12 out of 12 months

6. Proportion of ART patients who received CD4 control at 6 months

RBC/IHDPC/HIV Division QI Program Overview

Goals: Improve and sustain quality of HIV/AIDS clinical

services at health centers and district hospitals. Build national capacity in quality management Maximize utilization of National & facility level

electronic recording & reporting systems to identify areas for QI

Integrate QI in the existing clinical mentorship system

QI team Coordinates, monitors implementation Selects sites for inclusion based on transition

monitoring data & priorities of MoH Phased approach to implementation: 9 sites in first phase

The Electronic recording & reporting system

Facility level recording systems: IQ chart Open MRS

National level reporting system Tracnet

CellPhone

PCs/Internet

PDA/Smartphone

SAMPLE DATA

A GoR information system that supports the national HIV/AIDS and other health programs.

Builds on existing telecommunications infrastructure

Allows TRACplus to:• Collect real-time information

from the field via web, phone, mobile application, paper...

• Communicate and send alerts and information back out to the field in a timely and systematic way.

• View Rapid visualization of data – in charts, tables, graphs and dashboards

LocalApplications

Phone

TRACnet:

Program Strategies

Baseline and follow up data & trainingSource: Trac net, IQ chart and Open

MRS Validation of clinical performance data Site-level prioritization, gap analysis &

changes to improve care Coaching Visits Peer learning meetings

Selected QI Clinical Indicators

• % infants born to HIV INFECTED mothers who are tested for HIV using DNA PCR at 6-8 weeks

• % HIV INFECTED pregnant women that receive ARV prophylaxis

• % lost to follow ups among patients in Pre-ART care who are enrolled into care 4-15 months prior to assessment period

• % ART patients still on treatment 12 months after initiation

• % patients on ART who receive CD4 cell count measurement 6 months after being initiated on ART

• % patients who received ARVs for 12 out of 12 months

Coaching visits

• Onsite training

• Monthly & quarterly visits

• Quarterly data validation exercises• QI indicators• Tracnet indicators

May Jun

eJuly Aug.

SeptOct

.Nov. Dec. Jan.

Feb.March

AprilMay June

2011 2012

Basic QI Training9 Sites

Coaching Visits9 Sites

Performance Measurement Training9 Sites

Baseline Data Collection9 Sites

9 Month Data Collection9 Sites

Data Validation9 Sites

6 Month Data Collection9 Sites

QI Project Activities & Timeline

Baseline Data Collection15 Sites

Examples of Site level Identified Gaps

• Lack of harmonized appointment system

• In adequate provider & patient appointment reminder system

• Appointment registers with list of expected patients-not available: • CD4 & clinical follow up visits

Examples of Site level Identified Gaps conti…

In sufficient use of the ARV drug pick up appointment book ( table on the next slide)

Lack of early patient tracking mechanism Relatively long waiting time in some clinics Patient- level service satisfaction survey

Not routinely conducted Utilization of site level data:

to systematically improve quality of service

The existing appointment register: for ARV drug pick up

No.

Name Trac net Number

ART regimen/cotrimoxazole

Examples of QI Interventions

Site Level:• Waiting time reduced• Patient with missed appointments contacted early• 2 days after the actual date of appointment

• Grouping of patients for appointments (table on the next slide)

Examples of QI Interventions conti…

• Easy identification of patients with repeated missed appointments

• Solicited feedback from patients • Harmonized clinic visits• Utilization of site level data :

• Using QI approaches and methodsNational Level:• QI integrated in clinical mentorship guideline & program

Appointment system: with grouping of patients

Identification

Trac Net Number

Sex

Age Date of appointment ( mark √ if patient comes on the exact date, if not leave it blank & write the date when she/he comes in the blank space

Next Date of appointment

Next date of appointment

Next date of appointment

Next Date of appointment

Next Date of appointment

% ART Patients Received CD4 cell count measurement6 months after ART Initiation: Kigali sites

% ART Patients Received CD4 cell count measurement

6 months after ART Initiation: Nyamasheke sites

Conclusions

• QI program improves country capacity & ownership by supporting MOH staff & health workers to: • incorporate performance data, patient

feedback and, a system approach to improve quality of care

• utilize real time accessible health data for decision making

• The 6,9, 12, 18 and 24 months follow up data show improved results on CD4 control indicator

Lessons Learned and Recommendations

Improvement goals can be achieved

Leadership: a key component to support site-level program ownership

Patient feedback enhances improvement effort

MoH-Rwanda Scale-up QI to additional facilities, Develop district level pool of coaches

Acknowledgements

• MoH Rwanda• RBC/IHDPC/HIV Division • HQ-I• CDC-Rwanda• The pilot sites• ICAP• IHV/UMB

Thank You Murakoze

Merci