From the HIVQUAL International Update

Grace Children’s Hospital: Cotrimoxazole Prophylaxis

Grace Children’s Hospital, founded in 1967, is located in western Haiti just outside the capital of Port-au-Prince. The hospital serves a region with a population of approximately 67,000 people, including 3500 people living with HIV. Of the HIV+ population, 1142 are currently on HAART. The hospital’s HIV program is open 8:00AM until 4:00PM, Monday through Friday.

The hospital is staffed by 16 doctors, five counselors, one psychologist, one technician, 20 nurses, 13 lab techs, two data clerks, five outreach workers, one pharmacist, two adherence counselors, one nursing coordinator, and 18 auxiliary staff.

After baseline data revealed a low performance score of 32.4% in administration of CTX prophylaxis, defined as the proportion of HIV-positive adolescents who received cotrimoxazole prophylaxis in the preceding 6 months, staff determined to prioritize improvements in this area. In December 2008, Grace established a formal quality committee composed of staff from the hospital’s HIV clinic.

Staff created a project team specific to CTX prophylaxis, including three doctors, one data clerk, one counselor, and one nurse.

To systematically analyze the reasons for low performance, the team decided to meet weekly. At this meeting, staff constructed a fishbone diagram (pictured above). Staff also committed to improving the recording of patient information in the electronic medical record (EMR), both for purposes of care and to more accurately measure the impact of recent strategies. Reports were submitted to the committee for regular review at weekly meetings.



Careful analysis identified four specific areas for improvement activities. In response to the absence of a prescription protocol for CTX prophylaxis, the team created and implemented a protocol for prescription of CTX prophylaxis and prominently posted it in the clinic. They also found that CTX was not prescribed on a regular basis, nor was it regularly captured in the EMR. To address this issue, staff directed providers to regularly check for prescription of CTX in patients, complete patient records fully at each visit, and reinforce the need to capture CTX data in the EMR. 

As a result of this intervention, performance in rounds two and three improved markedly, up to 61.6% and 75% respectively (pictured).



Staff at Grace Children’s Hospital gained valuable insight as a result of this improvement project, such as the importance of a multidisciplinary approach to management of HIV treatment and care, and the importance of QI teams. 

While confident in their current accomplishments, staff is focused on future improvement in the face of remaining obstacles.

Power failures continue to impact all aspect of care, rendering consistent entry of patient information in the EMR challenging.

Grace Children’s Hospital staff made several recommendations toward improved quality of care. They plan to continue use of fishbone diagrams to better understand processes of care and stimulate systems level solutions. The team proposed  to establish additional project teams, and continue weekly review meetings to emphasize documentation and regular entry of patient info in the EMR. The QI team is highly motivated and formally committed to success in their QI work, a sentiment bolstered by their ongoing plan to submit new improvement strategies to the quality committee.

COUNTRY PROFILE:  HIVQUAL-Haiti
Team succeeds in the face of destruction after the 2008 hurricane season; Performance measurement process is facilitated by nation-wide EMR system.

With the third highest HIV/AIDS prevalence in the western hemisphere, Haiti has confronted a severe epidemic for many years.  The first cases of AIDS in Haiti were reported in the early 1980s, and today an estimated 190,000 Haitians are living with HIV/AIDS.  Coverage of antiretroviral treatment has expanded considerably in recent years, with more than 20,000 patients receiving ART at 51 sitse throughout the country...

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