Uganda – Outcome Collaborative

Date improvement activities began: 
October, 2009
Aims/objectives: 

The overall objective of the outcome collaborative is to strengthen practices of documentation, analysis, utilization and sharing of data generated at facility level; and for HCI to obtain and synthesize an effective and efficient package that can be used to increase the proportion of HIV+ patients in care with good clinical outcome across QI teams.

Outcome of ART in patients living with HIV/AIDS can be monitored through a number methods that is; Clinical, Immunological and Virological.
Given the setting in Uganda, clinical monitoring is readily available given the scarcity of the other two methods. Therefore the outcome collaborative works on this Clinical basis to generally monitor for and improve outcome to ART among HIV+ patients.
The objectives are:
i) Short term objectives:
- To improve measurement of parameters used in clinical monitoring of HIV+ patients in care.
- To improve documentation of findings by use of standardized codes and tools.
- To improve Opportunistic infection management
- To reduce occurrences of opportunistic infections by improving prevention methods.
ii) Midterm objectives:
- To improve clinical assessment skills of HIV+ patients by the health care workers.
iii) Long term objectives:
- To demonstrate good clinical outcome among HIV+ patients on ART.

Implementation package/interventions: 

In order to improve clinical outcome of HIV+ patients in care within health facilities offering HIV care and ART services, HCI is implementing the following strategies:
o During the 1st learning session, sites identified and analyzed ART delivery systems and possible theoretical treatment outcomes (health workers’ view ) among HIV+ patients in care, identified problematic areas that could be improved and developed possible solutions. In subsequent learning sessions, sites will share lessons learned and further analyze their systems, identify problematic areas and develop further solutions. Sites implement the developed solutions during action periods between learning sessions.
o During the coaching visits, site teams work with coaches to review their understanding of the clinical management, the use of the MOH patient monitoring tools and data use for improvement.
o Introduced the Outcome indicators, data forms and documentation journal in which sites document and track their QI interventions to improve patient monitoring and management, and link it to as evidence to whether the intervention worked or did not.
Through-out the implementation of the collaborative, effective changes will be noted from the participating sites and outlined into a change package that can be spread to other sites as best practices.

Measurement: 

Indicator #1 Percentage of patients on ART who are adherent to ARV medicines

Indicator # 2 Percentage of HIV + patients seen in a clinic who are in general care and /or receiving ART who are assessed for active TB at every visit.
Indicator #3 Percentage of HIV+ TB suspects sent for investigations in a month

Indicator #4 Percentage of HIV+ patients seen in the clinic and identified with active TB who are started on proper TB treatment in a month
Indicator #5 Percentage of HIV+ ART naïve TB patients started on ART in a month
Indicator #6 Number of TB infection control procedures put in place
Indicator #7 Percentage of patients on ART seen in the clinic that have shown clinical improvement.

Spread strategy: 

Results from the sites will be compiled and improvement changes distributed and implemented in sites while the collaborative is on-going. Best practices will be compiled on an on-going process.

Number of sites/coverage: 

The total number of facilities participating in the collaborative is 10 consisting of 1 Regional Referral Hospital, 6 District Hospitals, 3 Health Center IVs out of a total of 4,639 facilities in Uganda. These facilities cover 7 out of 80 districts and are located in 3 of 12 MOH regions. The estimated population covered by these sites is 6,800,000 people and 455,600 PLHIV.

Coaching: 

At the start of the HCI ART Collaborative, a group of coaches, known as the Core Team, was formed at the national level from Ministry of Health and HCI staff to support sites and develop technical strategy for the project. The Core Team build capacity of MOH regional staff, called Regional Coordinators to conduct trainings and coaching sites in quality improvement and clinical treatment. Regional Coordination Teams were set up in 12 health regions of Uganda with 5 members each representing data, laboratory services, pediatric HIV, logistics and general HIV care.
The Outcomes Collaborative sites are being coached by HCI/Core Team/Regional Coordinators once per month.
During the site coaching visits, the previous work plans drawn up by the site QI teams are reviewed to determine level of coverage. Coaches and the site teams work together to identify gaps in processes of care, analyze the causes and develop possible solutions. A new action plan is then drawn that is to be implemented by the site QI team in the subsequent action period, including collection of data to link changes introduced to improvements observed as concerns the treatment outcome. Technical support in other areas of HIV care is also provided.

Learning sessions & communication among teams: 

Learning sessions are to be held after every 6-months action period and will be attended by 2 to 3 representatives from the collaborative site teams. Learning sessions are facilitated by HCI staff, core team coaches and regional coordinators.
General topics covered include HIV care and ART, Logistics and implementation of QI in HIV care among others.
Sites prepare for the learning sessions by summarizing their improvement efforts highlighting key interventions that were effective (or not) in improving treatment outcome. From these, poster and PowerPoint or poster presentations are made and presented to the different participants of the sessions. Interactive sessions are then held by discussion and group work to brainstorm, compare and share notes on what works and what does not in different settings. Notes from participants’ presentations are summarized by the facilitators for future use.
Technical topics are presented by facilitators through PowerPoint presentations and copies handed out to participants. Any new guidelines, policies and/or publications from the MOH are also handed (or communicated) to participants at this forum.

Results: 

At the 1st action period baseline data indicated poor documentation of treatment outcome parameters in 70% of the sites, fair adherence (85%-95%) to ART in 50%of the sites, high levels of Tuberculosis (as most common opportunistic infection) in 80% of the sites.
Operational changes so far included are;
• QI teams formation with roles assigned to the different team members that contributes to the site’s objectives (all 10 sites have QI teams)
• Use of the revised MOH standard patient monitoring tools that include the patient HIV care/ART card, the pre-ART register, the ART register and the quarterly report form (all 10 sites are using some of the tool
• Use of the documentation journal to record data and interventions being implemented ( 7 of 10 sites )
• Adherence assessment for patients on ART (all 10 sites)
• Putting in place TB infection control procedures ( 6 out of 10 sites)
o 100% of sites have functional QI teams.
o 100% of sites in the collaborative have shown an improvement in documenting treatment outcome parameters in the HIV care/ART.
o 60% of sites have put in place TB infection control procedure below
The chart below gives a picture on one of the sites that has shown tremendous improvement in patient assessment for adherence right from improvement in documentation, to staff team work and engagement, to patient assessment for Adherence and finally to more clients adherent to ARVs.

(See file below for an example.)

Best practices/conclusions: 

Use of TB intensified case finding (ICF)forms
Use of expert client to carry out triage
Use of expert clients to carry out adherence assessment by use of adherence forms

 

Report Author(s): 
Connie Namajji
Organization(s): 
USAID, Health Care Improvement Project, URC, Ministry of Health Uganda
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