Using Quality Improvement Methods to Strengthen Provider-Initiated HIV Testing and Counselling Services at Hospital Level

According to the Uganda Health Demographic Survey (2011), a significant proportion—up to 44% men and 25% of women—have never had an HIV test, although more than 90% of Ugandans know about the importance of HIV testing and where they can access testing services. Consequently, most are less likely to know their HIV status.

It’s against this background that the USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project, in collaboration with the Ministry of Health, facilitates implementation of the Provider-Initiated Testing and Counselling (PITC) method at 14 public healthcare facilities to increase access to and demand for HIV Testing and Counselling (HTC) services. PITC is an approach through which healthcare providers initiate discussions on HTC with clients and provide the service to those eligible. At the hospital level, PITC can be practiced in a wide range of healthcare service delivery areas both in Out-patient and In-patient units.

Using Quality Improvement (QI) to improve PITC activities at Fort Portal Regional Referral Hospital

Qoutes from seleceted hospital staff about Quality Improvement approaches

Fort Portal RRH is one of the 14 high-volume healthcare facilities supported by the USAID/SUSTAIN project. In 2010, the project, worked with the hospital leadership and service provider teams, to start-up implementation of PITC for HIV across various service delivery points in the hospital. Service providers were trained and mentored as teams. Evaluation of performance data at that time showed that the hospital was persistently not meeting its monthly HTC targets.

Subsequently, USAID/SUSTAIN introduced the use of QI methods to the team to continually use their service delivery data to analyze performance, identify gaps and design and implement interventions to improve. Hospital management teams were also given technical support to use the same methods to improve effectiveness, efficiency and performance of staff in various units in delivering HTC services. Service delivery teams were trained in QI and supported to implement improvement projects focusing on streamlining client flow at high-volume service points, task-shifting and linking of tested clients  to care and treatment (for HIV-positive clients).

In January 2013, a hospital HTC QI committee comprised of Senior Nurses in management positions, the HTC focal person, ward in-charges, laboratory, records/data staff and HIV clinic staff representatives was formed. The committee was tasked to conduct support supervision of HTC services, especially on the wards and the Out-patient department, to increase access to and demand for HTC services. Other interventions implemented include:

             Conducting monthly performance review meetings (involving QI teams and hospital leadership at various levels) to review HTC performance results per hospital department.

             Using expert clients and volunteers to support healthcare staff in carrying out certain activities (updating of client registers, phlebotomy and escorting identified HIV-positive clients to the ART clinic for enrolment in care) to appropriately manage the workload. The number of volunteers allocated per department was based on client volumes.

On a daily basis, beginning to offer testing HTC services to clients earlier (8:00am) than other clinical services (9:00am) to ensure that clients  eligible for testing do so and are given their results before they are attended to by clinicians

Results
HTC GraphBy December 2013, all nursing and laboratory staff, supported by 8 HTC volunteers, were providing PITC services at 6 Out-patient and all In-patient service delivery units. Previously, there was only a single Voluntary HIV Testing and Counselling point in the Out-patient department. The number of clients accessing HTC services progressively increased between January–December 2013

Written by; Dr. Keith Baleeta, Clinical Care Coordinator at Fort Portal Regional Referral Hospital,Rosemary Nasaba, HTC Program Advisor, Kellen Baguma, HTC Program Officer with contributions from Julian Natukunda, Communications Specialist (USAID/SUSTAIN project), Jessica Ziegler, Knowledge Management Specialist at URC