Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Sombat Thanprasertsuk MD, MPH Department of Disease Control, MOPH Thailand 2 July 2013

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 ART is provided by government and private hospitals ART for all citizen is fully subsidized under 3 health care benefit schemes – Universal Coverage by National Health Security Office (NHSO) (case load share 60-70%) – Social Security Fund (10-20%) – Civil Servant Health and Medical Benefit (around 10%)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Gap 30%

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 ART cases Data from NHSO, up to end 2012 FY N=195,104N=6,461 Stop med. 248 (0.1%) Stop med. 248 (3.8%) AdultPediatrics

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Reduce disease burdens: – magnitude, mortality & morbidity – transmission – complication, etc. Standardized and harmonized treatment and care services Self monitoring and benchmarking at facility Streamlining quality of care in HIV/AIDS with others Maintain retention, minimize drop out, improve coverage Healthy PHA

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIVQUAL: an approach developed by NYSDOH since 1992, Initiative for performance measurement (PM) and quality improvement (QI) in Thai HIV clinic HIVQUAL-T based upon 3 conceptual pillars 1) HIVQUAL-T software for performance measurement 2) Quality improvement projects 3) Infrastructure building Integrated as cyclical process of repeated measurement and improvement Thailand MOPH, with technical collaboration from USCDC and NYSDOH, applied HIVQUAL-T since 2002

Kuala Lumpur, Malaysia, 30 June - 3 July hospitals762 hospitals (84.7%) of all 77 provinces HIVQUAL-TPediatrics HIVQUAL-T 2005

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 QI Technical Committee HIVQUAL-T Administration Steering Committee Monitoring and Evaluation Committee 8 Advisory committee Local QI Committee Regional/Provincial Regional QI Committee: Regional Offices of Health Security, Provincial Health, Disease Control, NGO, PHA hospitals Provincial QI Committee: Provincial Health Office, NGO, PHA, hospitals

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Activity to support Performance Measurement and Quality improvement activities Develop and revise HIVQUAL-T indicators according to national guideline for HIV/AIDS care and treatment Develop and revise guideline; and software to be friendly used, with automatic report printout at facility level Capacity building for personnel at all levels Develop website ( to disseminate information on HIVQUAL-T: software, publication, educational slides, results of indicators, and stories

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIVQUAL-T Indicators Group of indicators – CD4 Monitoring (5) – ART Monitoring (19) – OI Prophylaxis (10) – Disease Screening (17) – Health Promotion (12) Core indicators (12) Optional indicators (other) Pediatrics HIVQUAL-T Indicators 14 Indicators

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Role of Hospital Measure performance – Collecting data from samples of cases – Key in HIVQUAL-T software and calculate results (data can then be analyzed at provincial, regional and national level) – Compare overtime, analyze quality gap and causes; benchmarking with target or with others Develop quality improvement (QI) projects – Analysis and formulate project/activity to fill in the gap – Monitor and evaluate the results Re-do performance measurement

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, * by selected indicators YearNo. of hosp. participated Case-listSample ,87910, ,63935, ,77541, ,84448, ,0718,069 Note * most hospitals participated in 2010 using a more advance version of software

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percent of patients receiving a CD4 test at least once during the review period (CD4) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percent of patients receiving safe sex information or counseling (safe sex) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percentage of patients reported sexual activity receiving syphilis screening (Syphilis) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percentage of female patients receiving PAP smear (PAP) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percentage of ARV patients receiving VL test at least once (VL) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, 2010*-2012 by selected indicators YearNo. of hosp. participated Current cases Sample of current cases New cases Sample of new cases ,55949,86618,0279, ,55253,31819,0349, ,25443,11514,8187,762 Note * some hospitals participating in 2010 used former version of software

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Median of CD4 levels in HIV-infected patients who started ART in the assessment year at baseline (CD4_MD) Cell/cu.mm

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of HIVQUAL-T, by selected indicators Percentage of HIV-infected patients with pulmonary TB screening (TB) %

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of Pediatrics HIVQUAL-T, by selected indicators YearNo. of hosp. participated Case-listSample , ,4961, ,4543, ,0802, ,8786, ,2867,772

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Proportion of HIV-infected children on ART receiving a VL test during the review period (VL) % Results of Pediatrics HIVQUAL-T, by selected indicators

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Proportion of HIV-infected children on ART receiving adherence assessment in the last 3 visits during the review period (Adh) % Results of Pediatrics HIVQUAL-T, by selected indicators

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of selected indicators, HIVQUAL-T,

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of selected indicators, HIVQUAL-T,

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results of selected indicators, Pediatrics HIVQUAL-T,

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Discussion – Usefulness of HIVQUAL-T HIVQUAL-T, model proven to be a powerful tool to monitor and improve quality of HIV care – Hospitals not in HIVQUAL, found to have less performance level in several indicators, using the same measurement tool – Move on to other QI program such as STIQUAL, or if possible HEALTHQUAL Approach in HIVQUAL-T – Hospital or facility based, voluntary – Less workload, sampling to measure, meaningful data, according to indicators developed – QI intervention, its formulation and implementation, based on local analysis and context, exchange of stories among hospitals – Continuous process in measurement and quality improvement, including human capacity development

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Sustainability issue – Linkage to Hospital Accreditation system – Advocate to move towards humanized approach Holistic care Empowerment of patients, becoming partner in service Engaging more stakeholders/counterparts – Other tools to strengthen QI process Clinical tracer in HIV care Composite indicators Discussion - Challenge

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Acknowledgement IAS2013 National Health Security Office Dr Sorakij Bhakeecheep, Senior Manager, Fund Management of HIV/AIDS and TB Bureau of AIDS, TB and STIs, DDC Dr Sumet Ongwandee, Director Dr Cheewanan Lertpiriyasuwat Thailand MOPH-US CDC Collaboration Dr Achara TeeraratkulDr Chitlada Utaipiboon Dr Rangsima LolekhaDr Ake-chittra Sukkul New York State Department of Health Dr Bruce Agins All hospitals and agencies participating in HIVQUAL-T

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Thank you for your kind attention