HIVQUAL-Nigeria Speeds Ahead in First 18 Months
November, 2008In July 2007, HIVQUAL-Nigeria shifted into high gear with a series of high-level meetings between the Nigeria Federal Ministry of Health, CDC-Nigeria and HIVQUAL. Meetings were held to gain support and involvement from the National Guidelines Committee, key stakeholders, partner organizations, providers, and patients living with HIV/AIDS. With strong support at the national level, plans moved ahead quickly in the following weeks with the development of indicators, initiation of training sessions for key FMoH, CDC and facility staff, and data collection activities.
Located in West Africa, Nigeria is the largest country on the continent with a population of nearly 150 million – nearly a quarter of the population of Africa. Nigeria has an estimated adult HIV prevalence of approximately three percent, with 2.6 million Nigerians thought to be currently living with HIV/AIDS. Nigeria has the second highest number of individuals infected with HIV in the world, after South Africa.
With its large population and roughly 300 facilities providing HIV care throughout the country, HIVQUAL-Nigeria has been pushed forward thanks to strong central leadership. Dedicated participation from the FMoH is thanks to the firm commitments of the former and current Directors for Public Health, Dr. Ngozi Njepuome and Dr. Abdulsalam Nasidi, respectively.
With substantial momentum at the national level, indicators were promptly finalized. Within several months, trainings were held with representatives from all 20 pilot sites. Sites were chosen collaboratively by the FMoH and CDC-Nigeria, and were selected to represent all six geopolitical zones and a variety of stakeholders including facilities supported by implementing partners, the FMOH, and the Nigeria Department of Defense.
Reflecting an important priority of HIVQUAL-Nigeria and the FMoH, a commitment has been made to also involve patients in quality improvement and the implementation of HIVQUAL. In November 2007, two workshops were held for patient representatives and advocates to learn more about quality improvement and identify ways to empower patients to partner with their health care providers.
The first workshop with patients focused on basic quality improvement training, and served as an opportunity to gain their input for setting quality improvement priorities in Nigeria. Key issues identified by the patients were empowerment, stigma, quality of care, consumer involvement, rural access to care and the cost of care. Participants also expressed that patients needed to be more involved in their care at the national policy level as well as at the regional and facility level. The second workshop focused on patient empowerment, aiming to provide participants with the skills to actively involve themselves in the quality of their health care.
In November 2007, trainings were also held for staff representatives of the pilot sites, equipping facility teams with quality improvement and data collection skills in preparation for the first round of data collection. Site representatives were trained in sampling techniques, data analysis and usage of the HIVQUAL-Nigeria software.
In January 2008, six teams were assembled at the central level to travel to all 20 pilot sites for organizational assessments (OAs). The teams included representatives from the FMoH, CDC and partner organizations. Each was dispatched to one of the six geopolitical zones in Nigeria. For more on OAs, see the Methods box below.
The OAs provided the central team with crucial baseline information about the quality improvement infrastructure at each site, including their readiness to participate in the pilot. On-site trainings were also conducted during the visits to supplement the November workshops, and to continue preparations for the data collection process.
The customized HIVQUAL-Nigeria software was developed by HIVQUAL programmer Hugh Dai, MD. In total, more than 4,000 records were reviewed for the first round of data collection. Once abstracted, data were entered into the HIVQUAL software. Reports were emailed to the central team at the FMoH, led by Dr Aderemi Azeez.
The first round of data collection was completed in early 2008, and in May meetings were held to report back on the data to all stakeholders, including partner organizations, Nigerian and US government personnel as well as patient providers and facility representatives. Participants engaged in productive discussions on the data findings, exploring causes for both low and high scores as well as modifications to the indicator definitions and the software for the second round of data collection.
Participating facilities are now engaging in quality improvement activities, and preparations are underway for the second round of data collection which is slated for completion before the end of the year. Participation in HIVQUAL has encouraged facilities to implement a variety of specific improvements based on the results of the first data collection, in addition to forming engaged and quality improvement teams to implement the projects and promote a continuous QI focus amongst all staff. In many cases, teams have also included patient representatives.
At General Hospital Kafanchan in Kaduna state, a quality committee has been established to review performance. One key area targeted was patient waiting time – a factor that can impact a number of clinical indicators such as continuity of care and CD4 monitoring. Thanks to their participation, the facility reports that the ART team now considers quality an achievable and sustainable goal, and has been able to improve and streamline much of their work.
At Jos University Teaching Hospital in Plateau state, quality is now addressed at weekly in-house general seminars to ensure that all staff members are focused on improving patient care. Areas targeted for improvement since the first data collection include cotrimoxazole prophylaxis, continuity of care for patients on ART and ART provision for eligible patients. For a detailed description of the QI activities implemented at one participating pilot site, please see the “Spotlight” link below.
By early 2009, the team is planning to expand HIVQUAL-Nigeria from the original 20 pilot sites to an additional 40 facilities. Plans are also ongoing for a Nigeria Training-of-Trainers (TOT) workshop to be held in the coming months. The 3-5 day TOT will equip participants with the necessary skills to hold their own QI trainings, catalyzing the spread of the HIVQUAL model and basic QI methodologies to facilities and providers throughout Nigeria.
HIVQUAL-Nigeria is coordinated at CDC-Nigeria by Dr. Ahmad Aliyu (Program Specialist, Monitoring and Evaluation) and Dr. Ebunoluwa Jaiyesimi (Program Specialist, Care and Treatment), with leadership from Dr. Nancy Knight, Country Director. Additional support is provided by Dr. Karen Hawkins-Reed, Associate Director for Program Monitoring. During the pilot phase of the program, instrumental assistance and coordination was also provided by Dr. Alozie Ananaba, Dr. John Vertefeuille and Dr. Nasir Sani-Gwarzo. Dr. Seymour Williams of CDC-GAP in Atlanta has also provided essential support.
At the FMoH, coordination is provided by Dr. Aderemi Azeez (Head, Monitoring and Evaluation Unit, National AIDS/STDs Control Programme), Dr. Ganiyu Jamiyu (HIVQUAL Focal Point, NASCP) and Dr. E.B.A Coker (Head, HIV/AIDS Division).
For an example of a QI project from HIVQUAL-Nigeria, click here for a QI Spotlight from the newsletter.
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HIVQUAL International is supported through HRSA as the International Quality Center
for PEPFAR and through funding from UNICEF.
HIVQUAL International partners with the National Quality Center.
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