From the HIVQUAL International Update

 February, 2009

HIVQUAL-HAITI QI PROJECTS: Adherence Assessment 

At Hôpital de l’Universite d’Etat d’Haïti (HUEH), the quality committee decided to focus on adherence assessment for their QI project.  At baseline, the rate of adherence assessment at the facility was only 52.8%, despite the availability of an ARV adherence assessment tool developed and disseminated by the MSPP. 

First, an analysis of the tool was conducted to ensure that there were no problems with the tool itself that prevented its usage.  After testing the tool with 3 providers over 2 days, it was determined that providers were highly satisfied with the form and that the problem lay in encouraging providers to consistently use it.  The quality committee then implemented a number of interventions to promote its usage.  First, responsibilities for using the tool with patients were expanded beyond physicians to also include pharmacists, social workers and psychologists. 

In addition, weekly sessions were held with staff and posters were displayed in the clinic to remind personnel of the importance of using the tool to assess patient adherence.  Reports were given on a monthly basis to facility staff on the progression of their improvement.  Any providers with low completion rates were given extra attention to help solve problems or address barriers they were facing.  After three months of hard work by the facility staff and quality committee, the completion rate for the adherence assessment tool is now above 95%.  After using the tool consistently, the team has discovered that more than half of the patients are <90% adherent, which puts them at risk for treatment failure.  As Dr. Nathaelf Hypolitte of HUEH reports, “we couldn’t have known that because we weren’t doing the assessment.  Now we are deciding what next steps to take for those patients.”

HIVQUAL-HAITI QI Spotlight: Tuberculosis Assessment at Hôpital St Michel de Jacmel

   The Hôpital St Michel is located in Jacmel, a picturesque port city in the Sud-Est province of Haiti.  Both ART and HIV care are provided to more than 1,000 patients with HIV/AIDS.  After reviewing the first round of HIVQUAL data, the motivated and multi-disciplinary Quality Committee decided to tackle three key areas of improvement: PMTCT, adherence assessment and tuberculosis assessment.  TB assessment was addressed first, and a special team was assembled to improve PPD rates by 30% within three months.  The team is comprised of a physician, a nurse, two social workers, local community workers, and was led by Nurse Jeannina Jean François (Nurse François is now working at the regional level for the Sud-Est  Department of Health).

   Results from the first round of data revealed that only 2.1% of patients during the 6-month review period had received a PPD.  It was determined that the main barriers to patients receiving a PPD were their failure to return for a reading of the test, as well as their understanding of the importance of the test.  Staff also needed additional encouragement to regularly place PPDs.

   Once the causes for the low rate of TB assessment were determined, a number of interventions were planned, and improvement activities were launched in October, 2008.  First, staff were encouraged to reinforce counseling about the importance of PPD testing at every point of contact with patients.  Community workers were also directed to meet with patients to increase awareness of the PPD test.  Social workers were also provided with travel vouchers to give to patients who return for a reading of their PPD.  Documentation has been enhanced, with PPDs now mentioned on patients’ return appointment cards. 

   Additionally, when PPDs are placed, providers develop a plan with the patient to have the test read in 48 hours, particularly with patients from remote areas.  Patients are referred to a transit house for the two-day stay if they desire.  Finally, funds were procured for the follow-up chest X-rays that are to be given to patients with positive PPDs, and for a small thermos to transport and protect the PPD tests throughout the day.

   The nursing team recorded PPD results daily throughout the project, and reported monthly to the Quality Committee.  By November, 2008, the rate of PPD testing had risen to 25%, a significant improvement in just over one month.  Most importantly, the facility’s participation in HIVQUAL has “[given] us an opportunity to take a step back and really get a sense of the sort of work we are doing.  I can tell you that it’s the first time we’ve embarked upon this kind of work as a team,” reports former TB team leader Nurse François.

   With improvements in TB assessment underway, the Quality Committee is currently beginning projects to also improve adherence assessment and PMTCT; the success of the TB team has provided ample motivation to the teams assembled to tackle the other indicators.  Next up, future projects are being planned to also address rates of CD4 monitoring and ARV treatment for eligible patients.