Content. Background to Botswana national quality initiatives. Harmonisation of QA/QI: example of standards and

Transcription

1 BOTSWANA NATIONAL QUALITY MANAGEMENT TEAM Windhoek, Namibia March 2011

2 Content Background to Botswana national quality initiatives Harmonisation of QA/QI: example of standards and indicators for referral and retention E registers performance monitoring tools for QI ARV Program data analysis Summary remarks

3 Size and population density of Botswana 2009 estimate: 1.8m 61% aged % growth rate % death rate 0.5% migration 62yrs life expectancy 60% urban 81% literate 581,730 sq km Texas/France

4 Achievements of HCT, PMTCT and ART 41% of adult population tested for HIV and know results in the last 12 months (56% ever tested) ~90% of women tested at ANC and 98% by delivery ~95% of women on PMTCT <4% rate of mother to child transmission phased introduction of triple prophylaxis ~95% coverage of ART (160,000 patients on HAART

5 Government health facilities 3 referral hospitals 29 district/primary/ i t/ i / mine/mission hospitals 209 clinics 314 health posts 687 mobile posts 5

6 National strategies to improve quality The Botswana Government initiated quality assurance and improvement Health Inspectorate (external) Development of service standards and accreditation Leadership Development Program Equip management with knowledge/skills to coordinate QI National HIV/AIDS Quality Management Program (internal) Build sustainable infrastructure and a culture of quality Train all healthcare workers to participate in QI Monitor performance and support QI initiatives Facilitate peer learning and sharing of best practices

7 Goal of the National HIV QM Program To improve HIV care and preventative services in Botswana and contribute to the strengthening of the entire healthcare system by Approach: use HIV services as a vehicle for overall healthcare service improvement

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9 Standards and indicators for quality improvement

10 QA standards for referral and retention Processes ensure that all clients with TB / STI are referred dfor HTC HTC includes defined referral following diagnosis All HIV positive mothers are referred to HIV services after delivery All infants born to HIV positive mothers are treated t and tested t for HIV transmission according to guidelines ARV t d i i t d i th t t f t t it ARV agents are administered in the context of a system to monitor patients defaulting appointments and ARV pharmacy refills

11 Indicators for referral and retention (I) M&E: Number of HIV+ TB patients referred to HIV care and support services during TB treatment, of all HIV+ TB patients M&E: Number of males circumcised who return at least once for postoperative follow up care within 14 days of surgery QM: Percentage of clients who tested HIV+ in the past 6 months and who have a documented referral for treatment, care & support services (possibility of monitoring presentation after referral) M&E: Percentage of HIV positive pregnant women newly enrolled into HIV care and support services QM: Percentage of HIV exposed babies with samples taken for HIV testing from 6 to 8 weeks of age

12 Indicators for referral and retention (II) QM: Percentage of HIV+ infants initiated on HAART within one week after receiving a positive HIV test result QM: Percentage of HIV+ patients who have never been on HAART and with at least one HIV clinic visit in the last six months who had at least one CD4 cell count test in the last six months QM: Percentage of HIV+ patients on HAART and with at least one HIV clinic visit in the last six months who had at least one viral load test in the last astsix months M&E: Percentage of adults and children with HIV still alive and known to be on treatment 1/2/5 //5years after initiation of ARV therapy Breakdown of lost to follow up, stopped therapy, died, transferred in/out

13 Leveraging performance monitoring tools for quality improvement

14 Background PIMS Patient Information Management System Electronic medical record for ARV patients In facilities providing ART since start of program in 2002 Currently over 120 facilities i nationwide id Additionally, some key hospitals have centralised IPMS A few clinics and health posts do not have electricity E registers Capture data from non ART programs electronically Minimise burden Replicate paper registers to reduce training and data entry Integrate system to reduce repeat entry of demographic data etc

15 E systems for quality improvement Develop systems to support quality patient care Current Lists of defaulters / lost to follow up Record contact details of clients, next of kin, buddies Document follow up efforts Enable efficient i reporting Data integration and analysis at national and district level Link to cellphone systems for reminders / follow up Next step Monitor referral between programs

16 PIMS E registers

17 PIMS / E registers LTFU / Defaulters Patient names

18 Patient names

19 Patient name

20 PIMS / E registers reports

21 Patients on HAART with ihno recent visits ii Patient names

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23 M&E monthly reports & national ARV program dataset

24 Summary M&E data from ART program ~ 1,800 starting HAART per month ~ 160,000 patients on HAART end Jan 2011 includes ~ 10,000 children (<15 5y years) ~ 6,000 LTFU while on HAART ~ 1,800 LTFU while eligible ibl for HAART but not yet started t ~ 17,000 died while on HAART ~ 2,000 died while eligible but not yet started on HAART ~ 700 died after diagnosis but not yet eligible for HAART ~ 500 patients stopped HAART

25 Analysis of national ARV dataset Initiation between 2002 and ,232 patients median follow up 2.4yrs (IQR yrs) 333,000 patient years at risk 61% women Median age at initiation: 35 yrs (IQR yrs)

26 Loss to follow up and deaths: 23,495 patients initiated in 2005 o Percent tage of pa atients wh initiate ed 10.0% 8.0% 60% 6.0% 4.0% 2.0% 0.0% Died 6.8% 8.2% 3.2% 5.0% Lost to follow up 9.1% 6.3% 9.6% 9.7% 6.8% 7.0% Years of follow up after initiation

27 Loss to follow up and deaths: 13,328 patients initiated in % Died Lost to follow up Percent tage of pa atients wh initiate ed o 4.0% 30% 3.0% 2.0% 1.0% 0.0% 3.2% 0.8% 0 1 Years of follow up after initiation

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29 Botswana National HIV QM Program: Being aligned with the national QA program need to align indicators, and training as well as structures Integrating with and leveraging monitoring systems using data collected for routine care increases amount of data available incentive for data quality? developing data quality improvement structures and initiatives Potential to monitor referral/retention between programs E registers unlikely to provide all data needed for QM g y p Q e.g. client satisfaction surveys

30 Acknowledgements: All healthcare workers who capture data into e registers Patients who provide information and wait patiently Partners who support QM and data quality BOTUSA Partners who support performance monitoring Botswana Harvard Partnership, SCMS, I TECH HEALTHQUAL for all their support especially Clemens Steinbock