Adolescent HIV Care and Treatment

1. Adolescent HIV Care and Treatment Module 13: Monitoring, Evaluation, Quality Improvement, and Supportive Supervision

2. 2 Module 13 Learning Objectives Discuss the importance of routinely monitoring adolescent HIV care and treatment activities. Discuss how information from monitoring and evaluation can be used to support programme improvement. Describe the purpose of Quality Improvement (QI). Define and describe supportive supervision.

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4. 4 Session 13.1 Objectives Discuss the importance of routinely monitoring adolescent HIV care and treatment activities. Discuss how information from monitoring and evaluation can be used to support programme improvement.

5. 5 Why do you think it is important to keep records and monitor our work with adolescents Why do you think it is important to keep records and monitor our work with adolescents? Do you know how the data (information) that you record is used at the facility level and at the national level? Have you ever received feedback from district health mangers on the monitoring data you or your clinic submit?

6. 6 Monitoring Routine collection and tracking of key programme data over time (e.g., daily, monthly, quarterly) Process that helps to identify problems early so that they can be corrected quickly Requires that data be collected, compiled, and analysed on a routine basis, e.g., # of adolescents enrolled in HIV care and receiving ART # of adolescents retained in care over time Types of clinical and support services offered to adolescents

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8. 8 Monitoring (Continued) M&E of adolescent HIV CT programmes helps to: Assess whether the programme is meeting its targets, and Identify and improve implementation problems Routine M&E necessary to gather info on: Individual outcomes (e.g., Is the client responding to treatment? Is she being retained in care?) Programme outcomes — cumulative tally of individual outcomes; insight into strengths and areas for improvement (e.g., Is the programme retaining adolescent clients in care? Are all eligible adolescents receiving ART?)

9. 9 What are “targets”? Can you give an example of a target? What are “indicators”? Can you give an example of an indicator?

10. 10 Targets Specific goals established before a new programme or service is implemented and on a regular basis thereafter Example: To ensure that 95% of eligible adolescent clients initiate ART

11. 11 Indicators Indicators are summary measures used to help indicate the status of your programme’s activities Data gathered to help indicate status of programmatic activities; compared against targets to assess performance Reflect a certain timeframe

12. 12 Indicators (Continued) HIV care and treatment indicators established nationally according to programme needs, resources, and standards; often defined in the national strategic plan for HIV National level indicators generally cover service delivery, quality of care, and management-related information Can be calculated for facility, district, or national levels depending on need and use of data Some facilities also have own indicators Important to measure changes in indicators over time

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14. 14 What is “evaluation”? What questions might an evaluation answer?

15. 15 Evaluation More detailed process than monitoring; helps understand what indicators are telling us and how well the programme has met expected targets Typically conducted at specific time periods Should be conducted regularly to examine programmatic changes over time; help to determine if changes can be attributed to our programme Helps identify areas of strength and weakness and enable investigation and correction of problems

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18. 18 At your clinic, how are the monthly summary forms and monthly reports completed? (Who completes them? Where do they get the information from to complete them?) To whom are they submitted? These reports are analysed at the district, but who at your clinic analyses them as well? What is done with information in these monthly reports? Is it ever used to improve/modify services? Who has an example?

19. 19 Reporting

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21. 21 Programme Modification At every level, monthly summary forms should prompt discussion on modifications and improvements needed to better meet targets Requires discussion: What is the problem? How will we address the problem? What is the plan of action (who, by when, what funding)? How will we decide if the plan is working?

22. 22 Adolescent HIV Care and Treatment Data Collection Part of existing national system; uses existing national HIV care and treatment forms and registers; no separate system with adolescent-specific forms Usually, adolescent data captured in national forms for paediatric HIV; if care provided in adult HIV clinic, use national forms for adult HIV care and treatment All records must be kept in a secure location and no identifying data should leave the site Ensure that data is accurate and complete and that data collection protocols are followed

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24. 24 Adolescent HIV Care and Treatment Data Collection (Continued) Ward or clinic registers General HIV counselling and testing register Patient care card HIV care summary sheet Paediatric clinical follow-up form Paediatric ARV eligibility form Paediatric adherence form Pharmacy logbook/register Patient status form TB diagnostic worksheet and TB screening tool Paediatric patient locator form

25. 25 Tracking Missed Appointments Use an appointment book to track upcoming and missed appointments; follow-up system needed to contact clients and caregivers when appointments are missed Follow-up system requires: A working appointment system Contact by phone or home visit (in urban areas, calling or SMS may be used; in rural areas, home visits by community workers, NGOs, Peer Educators, family members, or friend networks) Adolescent and/or caregiver consent to contact; system should obtain contact information and routinely request consent to follow-up

26. Exercise 1 Using Data for Decision-Making: Small group work and large group discussion

27. 27 Exercise 1: Part 1 of Small Group Work For which indicators is Clinic Make Believe doing well and meeting their targets? How do you know? For which indicators is Clinic Make Believe NOT meeting its targets? How do you know?

28. 28 Exercise 1: Part 1 of Small Group Work (Continued) If the number of adolescents enrolled in care in Q4 (the 4th quarter) of 2009 was 450 and the number of adolescents receiving ART was 290, would you say that in 2010 they are doing better or worse enrolling clients in ART? Which areas should Clinic Make Believe staff focus on improving?

29. 29 Exercise 1: Part 2 of Small Group Work Identify one area needing improvement at Clinic Make Believe; discuss: What is the problem? How should we (assuming we are the managers at Clinic Make Believe) address the problem?

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31. 31 Session 13.2 Objectives Describe the purpose of Quality Improvement (QI). Define and describe supportive supervision.

32. 32 What does “quality” mean to you when you think about adolescent HIV care and treatment services? How do you think facility managers would define quality? What about adolescent clients? How would they define quality? How do you think monitoring and evaluation and QI are related?

33. 33 Quality Improvement (QI) Means by which activities are routinely evaluated to ensure the services offered follow established guidelines and standard operating procedures Also referred to as quality assurance (QA) Purpose is to identify problems so that they can be corrected, thereby improving services Should be a routine part of the normal functioning of health facilities; incorporates procedures in which all staff, at all levels, should be involved

34. 34 Methods to Assess Quality Necessary to use a variety of methods to assess quality Standard monitoring tools provide no information on quality Examples of QI activities: Examine and evaluate: Quality and youth-friendliness of services Compliance with national guidelines, SOPs and protocols for HIV CT Adequacy of space and attention to privacy and confidentiality Linkages to ongoing support and community-based services

35. 35 Methods to Assess Quality (Continued) Examples of QI activities (cont’d): Periodic reviews of records, with staff feedback Direct observation of procedures and counselling sessions Periodic assessments of youth-friendliness; youth participation Interviews with staff to obtain feedback on specific indicators Individual interviews or focus groups with adolescent clients; with caregivers of adolescent clients Client exit interviews or anonymous surveys Evaluation of physical space, client flow, and time concerns Meeting with representatives of services where adolescent clients and caregivers are referred

36. 36 What methods do you think you would use if you wanted to find out if, for example, your clinic’s adherence preparation visits were adequate?

37. 37 Discuss possible solutions/interventions to the following problems identified through QI activities: Older adolescents often miss their clinic appointments There is an increase in the number of adolescent clients presenting with STIs Many younger adolescent clients have not been fully disclosed to and therefore do not understand why they need to take medicines every day Adolescent clients think the support group is a “waste of time” and regular attendance is low

38. 38 How often should QI be conducted? Initially, daily or weekly QI activities allow for immediate follow-up to correct identified problems As services become established, QI review should become a formal part of monitoring activities at designated intervals (e.g., monthly progressing to quarterly)

39. 39 What are the qualities you believe should be associated with “supportive supervision”? For example, if you were expanding adolescent care and treatment services within your facility, what could your supervisor do to support you and help you to set up these services in line with national care and treatment guidelines?

40. 40 Do you think using supportive supervision would improve performance of healthcare workers who are being supervised?

41. 41 Supportive Supervision QI activities include assessing results of the QI review and planning a response Often weaknesses require supervisors to work with staff to address the problems via supportive supervision Supportive supervision requires the supervisor to work with staff to: Establish goals Monitor performance Identify and correct problems Proactively improve the quality of services

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43. 43 Supportive Supervision (Continued) Aims to: Obtain information on programme functioning and quality Improve HCW performance by providing one-to-one support Acknowledge good practices by providing positive feedback Involve supervisors, HCWs, and adolescents themselves to improve service provision Facilitate on-site, participatory problem-solving Assure the programme is successful in meeting the needs of ALHIV and their caregivers and families Motivate staff

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46. 46 Module 13: Key Points Monitoring and evaluation is the standardised process by which data related to the delivery of services is collected and evaluated. This data can be used to monitor progress in the implementation of adolescent care and treatment services from the facility perspective. Indicators provide information about key service interventions. Indicators can be calculated for facility, district, or national levels depending on need and how the data will be used. Indicators are calculated using routinely collected data that are recorded in registers and summarised on monthly summary forms.

47. 47 Module 13: Key Points (Continued) A review of the monthly forms that summarise monitoring data can help to identify service strengths and weaknesses. Programme successes and weaknesses need to be communicated back to staff to initiate discussion on how weaknesses can be addressed. Quality Improvement is the means by which activities are routinely evaluated to check that the services offered by the multidisciplinary team are following the established guidelines and standard operating procedures. Services not following established procedure, once identified, can be corrected. Information that supports QI activities includes that from monitoring and evaluation processes.

48. 48 Module 13: Key Points (Continued) A variety of methods may be used to conduct QI, including: Periodic reviews of records Direct observation of healthcare workers’ (and Peer Educators’) activities Assessments of youth-friendliness of services Individual interviews or focus groups with adolescent clients and caregivers

49. 49 Module 13: Key Points (Continued) An important component of responding effectively to QI findings is to provide supportive supervision. Supportive supervision requires collaboration between the supervisor and staff to: Establish goals. Monitor performance. Identify and correct problems.