Instruction Manual for Implementing a Gaps Analysis Framework to Guide Quality Improvement Decision-making in ART Programs

A major function of the USAID Health Care Improvement Project (HCI) is to develop and validate methods for strengthening the capacity of health systems to provide and sustain high quality HIV/AIDS services. The quality improvement framework used to guide these activities recognizes that the fundamental objectives of HIV/AIDS programs should be to: 1) provide services for all who need them, 2) retain all those who access services in the continuum of care, and 3) achieve optimal health outcomes for all those who are retained in care. 
Due to the great clinical complexity of HIV/AIDS and of the issues associated with it, many process indicators have been generated in the HIV/AIDS field to monitor and evaluate the quality of treatment programs. This multitude of indicators can make the identification of priority areas for quality improvement very difficult and lead to QI activities that do not always address key program weaknesses.   In 2009 HCI began testing the Framework for Quality Improvement in Chronic Care of HIV to guide quality improvement activities for HIV/AIDS treatment programs. The Framework offers an approach, for identifying and prioritizing problems and for evaluating the long term effects of changes, that is grounded in the overall program outcomes for: coverage of eligible persons, retention of patients in treatment, and clinical outcomes for patients in treatment. These outcomes are defined by a small set of indicators which expose outcome “gaps” by comparing potential to actual numbers of people with HIV who: 1) receive treatment, 2) are retained in treatment, and 3) achieve good clinical outcomes. At pilot sites, the framework has been useful for guiding HIV treatment programs in choosing their QI priorities and in monitoring overall program improvement.  
This manual describes the method for setting up the framework. Some or all of the data needed for this framework may be readily available, or information systems may need to be improved in order to gather necessary data. The meaning of the “gaps” quantified through this framework can also vary depending on the situation, and this should be taken into account in measuring, interpreting and addressing gaps in coverage, retention and clinical outcomes. Gaps may take long periods to decrease or close. Short term quality improvement decision-making therefore should not simply be based on the information in this framework. Rather, the framework should be used for long term program monitoring and decision-making, while specific process and/or intermediate outcome indicators, chosen to address one or more of the three outcome gaps described in this framework, should be used to track and make short term QI decisions.
A related tool for the use of the ART Gaps Framework is the ART Framework Coverage Calculator, a Microsoft Excel spreadsheet that provides a practical way for estimating ART need in a population.  The coverage calculator may be downloaded from the link below. 
Report Author(s): 
Shakir F and Gaudreault S
ASSIST publication: 
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