HIVQUAL-Namibia Plans for 2nd Data Collection
September, 2008Namibia has a large land mass of more than 800,000 square kilometers, much of which is desert. With a population of just 1.8 million people, it is one of the most sparsely populated countries in the world. However despite its thinly distributed population, Namibia has an estimated HIV prevalence of 19% among pregnant women and 15.3% among all adults. With an estimated 196,000 PLWHAs scattered across a large geographical area, Namibia faces many challenges in delivering and monitoring care.
Given these challenges and their prior experience with other country-wide initiatives, the HIVQUAL-Namibia team recognized early on that a regional approach was needed to support quality activities in a sustainable way. During the engagement process, starting in 2006, this model was the basis for site selection, data collection, QI training and coaching and mentoring.
The first round of data collection was preceded by 3 intensive 2-day regional trainings with at least 3 representatives from each of the 16 pilot sites. These trainings were opened by Ms. Ella Shihepo, Director of Special Programs at the Ministry of Health. Also facilitating were Dr. Ndapewa Hamunime of the Ministry of Health and Social Services, Dr. Gram Mutandi from CDC and Dr. Jan King, HIVQUAL International. In addition to gaining an understanding of the indicators and data collection processes, the teams were able to start the quality improvement process through teamwork, brainstorming and development of improvement strategies for specific issues of concern in their facilities. These trainings also marked the beginning of peer learning, sharing of successes, frustrations, and strategies toward improvement. The trainings were held in Windhoek (the capital), Swakopmund (Western coast), and Oshakati, which is in the North on the Angolan border that was recently ravaged by severe flooding.
As with all improvement activities, success begins with leadership. HIVQUAL-Namibia has been led by Dr Ndapewa Hamunime. Dr. Hamunime is the Senior Medical Officer In-Charge of Case Management, the MoHSS unit which oversees HIV/AIDS treatment, care and prevention. She has included regional staff in trainings to increase skills at the Ministry level as well as train individuals to provide coaching and mentoring at the facility level.
After the baseline data collection and analysis were completed, national, regional and district level benchmarking and comparative reports were developed and will be used to drive improvements and inform national priorities. Two quality improvement training workshops were held in April, 2008 to present the data to the pilot sites and to prepare them for the implementation of quality improvement projects. Sites were guided through the process of examining the data, choosing targeted projects, and performing a root cause analysis to begin development of intervention plans. In June, the data was also presented to the MoHSS Technical Advisory Committee, chaired by Dr. Ishmael Katjitae.
In October, the second round of data collection is scheduled to begin at the 16 pilot sites. In preparation for this round of data collection, customized HIVQUAL-Namibia software has been developed to streamline data entry, analysis and reporting. Trainings for facility staff on data collection procedures and use of the new software are planned for the coming months. A software user guide is also in development.
Namibia has also adopted several unique indicators, in addition to the traditional HIV management indicators (such as CD4 monitoring, ARV Therapy and PCP Prophylaxis). To highlight important issues affecting quality of care, the HIVQUAL-Namibia team included food security and alcohol screening to their set of indicators. An inadequate supply of food in certain areas of Namibia hampers achievements in clinical outcomes for people living with HIV. Encouragement is needed to improve screening and increase referrals to NGOs offering nutritional and food security services. Alcohol use also negatively affects disease progression, limits deliverable clinical outcomes and adherence to ARVs, enhancing transmission among patients living with HIV. Both indicators were felt to be vital steps leading to the generation of data that will foster partnerships between clinical teams and community-based organizations providing services to HIV-infected individuals. Performance rates for these indicators during the pilot data collection were low at some sites, as expected, indicating the importance of highlighting these issues and targeting them with improvement activities. Concerns about these additional indicators were discussed openly during trainings, including conducting assessments of food security in areas where nutritional resources are often lacking. Another common concern was the burden of documentation for screenings and referrals.
Improvement projects began after the first round of data collection, with clinic teams implementing a wide variety of projects. Several teams focused on improving TB screening rates and raising the number of eligible patients receiving Isoniazid Preventive Therapy (IPT) for TB prevention. In many cases, improvements were implemented through a systems-oriented approach of improving documentation and record keeping through the introduction of new clinic forms and ART cards with specific fields for TB screening and prevention. These new systems not only improve documentation, but will also provide reminders to providers to regularly screen patients and provide preventive treatment when necessary. For example, one team developed a special TB screening checklist form to be attached to each patient file so that all patients can be properly assessed. Another team found that the major barrier was dispensing IPT at separate TB clinics, leading to considerable loss to follow-up. To improve patient adherence and follow-up, the team is now providing IPT within the ARV clinic, in conjunction with improved patient education. For an extensive description of one of these QI Projects, see the box on page 2.
Many clinic teams also targeted other indicators such as CD4 monitoring, prevention education, adherence assessment, PCP prophylaxis, alcohol screening and food security. Improvements were implemented using similar approaches of improved information systems to encourage improvements in care. At Onandjokwe Hospital, the team worked to encourage regular CD4 monitoring through weekly meetings with multidisciplinary staff, stressing the importance of requesting regular CD4 counts and documenting results in patient files. At each meeting 10-15 patient files are examined by the group to monitor whether improvements were being made.
Like at Onandjokwe Hospital, improvement projects at other clinics are usually initiated through group discussions with facility staff of all disciplines. This promotes a collaborative approach to the QI activities and creates maximum staff buy-in and commitment to improvements in care. Improvements are expected across many indicators in the next round of data collection. In many cases, chart reviews have already shown improvements.
Once the second round of data collection is completed in October, follow-up meetings are planned in each of the 3 regions for November and December. These meetings will primarily focus on improvement activities conducted at the site level. Facilities will present their quality projects, improvement strategies, successes, and challenges. Training in additional improvement tools and techniques will be included to continue facility level capacity building. In the meantime, the central HIVQUAL team has continued to provide support to sites where necessary, and is implementing a follow-up system via telephone to monitor the progress of improvement projects.
HIVQUAL-Namibia is managed on a daily basis Dr Gram Mutandi, who is based at both the MoHSS and the CDC GAP office. At CDC, the team also includes Claire Dillavou, MPH, the program’s data manager. Dr Ndapewa Hamunime leads the team from the MoHSS. Additional support is provided at MoHSS by Ms Francina Kaindjee-Tjituka, Ms. Ria Bock, Ms Annatjie Tobias and Ms. Wilhemina Kafita.
For an example of a QI project from HIVQUAL-Namibia, 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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