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Endris Mohammed 1,2 , Byringiro Vianney 2 , Sabin Nsanzimana 2 1 : Rwanda Family Health Project 2: Rwanda Bio Medic

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 Mohammed 1,2 , Byringiro Vianney 2 , Sabin Nsanzimana 2 1 : Rwanda Family Health Project

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Endris Mohammed 1,2 , Byringiro Vianney 2 , Sabin Nsanzimana 2 1 : Rwanda Family Health Project 2: Rwanda Bio Medic

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  1. 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. • EndrisMohammed1,2, ByringiroVianney2, Sabin Nsanzimana2 • 1: Rwanda Family Health Project • 2: Rwanda Bio Medical Center (RBC) • IAS 2013, Kuala lumpur, Malaysia • July 1, 2013

  2. 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

  3. 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

  4. 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

  5. Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda Cohort 2 Transition 6 Sites Cohort 3 Transition 26 Sites Cohort 3.5 Transition** 20 Sites Cohort 1 Transition* 18 Sites 2010 2011 Oct. March Sept. Jan. Feb. June July Aug. July May Dec. Sept Aug. Nov. June April May C1 12-Month FU C1 Baseline C1 6- Month FU C2 Baseline C2 6-Month FU C3 Baseline C3 6-Month FU *The Cohort 1 transition occurred in March 2010 C3.5 Baseline C3.5 6-Month FU **The financial transition for Cohort 3.5 sites will occur in March 2011

  6. Track 1.0 Transition M&E Timeline: Reference CDC-Rwanda Cohort 4 Transition 6 Sites 2013 2011 2012 March Nov. Feb. June Jan. April July Oct. Dec. Aug. Sept. Nov. May Feb. Dec. Jan. March Oct. C1 18-month FU C1 24- Month FU C2 12-Month FU C2 18-Month FU C2 24-Month FU C4 Baseline C4 12-Month FU C4 6-Month FU C3 12-Month FU C3 24-Month FU C3 18-Month FU C3.5 12-Month FU C3.5 24-Month FU C3.5 18-Month FU

  7. List of clinical indicators used in the transition assessment • The proportion of HIV+ pregnant women eligible for triple therapy prophylaxis who received triple therapy prophylaxis • The proportion of HIV+ pregnant women eligible for triple therapy for life who received triple therapy for life • Proportion of partners of pregnant women presenting for their first antenatal care consultation who are tested for HIV • Proportion of infants born to HIV+ mothers who received ART prophylaxis at birth • Proportion of infants born to HIV+ mothers that have PCR at the age of 6 weeks • Proportion of currently enrolled patients on Pre-ART and ART who are on CTX

  8. List of clinical indicators used in the transition assessment conti… • The proportion of ART patients who are still on treatment 12 months after initiation • The proportion of patients newly enrolled in HIV services who were screened for TB • Number of patients newly initiating on ART during the reporting period a. Pediatric patients b. Adult patients • Number of patients currently on ART at the end of the reporting period • Proportion of patients who received ARVs for 12 out of 12 months • Proportion of ART patients who received CD4 control at 6 months

  9. 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

  10. The Electronic recording & reporting system • Facility level recording systems: • IQ chart • Open MRS • National level reporting system • Tracnet

  11. Cell Phone Phone PCs/ Internet TRACnet: • 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 PDA/ Smartphone Local Applications

  12. Program Strategies • Baseline and follow up data & training • Source: 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

  13. 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

  14. Coaching visits • Onsite training • Monthly & quarterly visits • Quarterly data validation exercises • QI indicators • Tracnet indicators

  15. QI Project Activities & Timeline Performance Measurement Training 9 Sites Basic QI Training 9 Sites Coaching Visits 9 Sites 2012 2011 Jan. June Aug. Dec. Sept Feb. July March Oct. Nov. June April May May 9 Month Data Collection 9 Sites Baseline Data Collection 9 Sites 6 Month Data Collection 9 Sites Data Validation 9 Sites Baseline Data Collection 15 Sites

  16. 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

  17. 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

  18. The existing appointment register: for ARV drug pick up

  19. 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)

  20. 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 methods National Level: • QI integrated in clinical mentorship guideline & program

  21. Appointment system: with grouping of patients

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

  23. % ART Patients Received CD4 cell count measurement6 months after ART Initiation: Nyamasheke sites

  24. 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

  25. 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

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

  27. Thank You Murakoze Merci

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