1. Achieving the “First 90” for Children in Tanzania: A QI Collaborative to Enhance Pediatric Provider Initiated Testing and Counseling (PITC)
Gillian Dougherty, Kevin Clarke, Ruby Fayorsey, Modestus Kamonga, Sajida Kimambo, Doris Lutkam, Caitlin Madevu-Matson, Veronicah Mugisha, Hussein Mtiro, Shinje Msuka, Milembe Panya, Angela Ramadhani, Julius Sipemba, Peris Urasa, Miriam Rabkin
Hello I am Gillian Dougherty and I presenting on behalf of a much larger team on a Peditraic PITC project where we used the QIC methodology for implementation in two regions in TZ

2. The Quality Challenge
Despite many efforts, Tanzania has low pediatric (< 15 y/o) ART coverage rates
Barriers include suboptimal use of pediatric PITC, as well as linkage from testing to treatment
Past interventions have included development of national guidelines and training curricula for both pediatric PITC and quality improvement (QI)
This project built on those assets using the QI Collaborative methodology
Despite remarkable progress in the scale-up of HIV care and treatment services, Tanzania (has the world’s second largest burden of HIV-infected children yet to be started on treatment.
One essential component of improving ART rates is to improve PITC performance among already-ill pediatric sub-populations.
Already-ill HIV-infected children coming to health facilities for care present a unique opportunity to reach those most in need of HIV care and treatment rapidly.

3. The Pediatric PITC Collaborative
Project design:
Buy-in from the Ministry of Health, Community Development, Gender, Elderly, and Children and Regional Health Management Teams (RHMT)
Building blocks in place: national guidelines, training, and M&E systems
Collaborative development of site selection criteria, data collection methods, and aim statements
Partners included MOHSW, NACP, two local implementing partners (AGPAHI and CSSC) and RHMTs
In 2014,ICAP received support from CDC to design and lead a QIC with 2 local IP’s In collaboration with the MOH and NACP at 24 sites in TZ.
Tanzania has a strong NACP lead and supported HIV program QI infrastructure and the QIC is a nationally endorsed methodology which has been tested numerous times under various conditions.

4. What is the QI Collaborative Approach?
An organized network of sites (districts, facilities or communities) that work together on a focused program topic area using QI methods and tools.
For a limited time, typically 12 to 18 months
Share aim statements, indicators, and measurement processes
Regular forums (quarterly) for data review, shared learning and spreading successful changes
Final “harvest” meeting of successful interventions, tools and resources
So, before we move into a description of project. What exactly is the QIC approach?
Developed by the Institute for Healthcare Improvement (IHI) in the early 1990s, the QI collaborative approach (also known as the “Breakthrough Series” or BTS) is a highly effective method to create rapid improvements across a range of organizations.
involves multiple teams working across different units, organizations, or regions to make improvements toward one specific aim.
It entails having shared aim, the same indicators, and an identical measurement process (including operational definitions, data collection, and reporting cycles) across all participating organizations.
Participating health facilities implement their own locally driven change ideas using QI methods and tools.
QI Collaboratives are time-limited and typically aim to achieve their improvement goals within six to 18 months   

5. Adapted from IHI Breakthrough Series
Select Improvement Aim
Scale up and spread
Convene expert meeting
Identify best practices Develop aim statement,
Indicators, data SOPs
“Harvest” of successful interventions, tools, resources
The
QI Collaborative
Approach
Adapted from IHI Breakthrough Series
Learning
Session 4
Select/prepare sites
This is a pictorial representation of the QIC approach and the specific processes involved in implementation of this approach.
As you can see her a key feature includes Learning sessions where all teams come together to present their data and progress to achieving the aim.
They also report on all their change interventions implemented.
The QI collaborative approach uses the Model for Improvement as the improvement framework and relies on organizations to implement the PDSA methodology to implement and test change ideas.
PLAN DO
STUDY
ACT
PLAN DO
STUDY
ACT
PLAN DO
STUDY
ACT
Learning
Session 1
Learning
Session 2
Learning
Session 3
Action Period 1
Action Period 2
Action Period 3

6. The Peds PITC QI Collaborative
24 health facilities supported by CDC PEPFAR partners AGPAHI and CSSC
The Ped PITC QIC was comprised of 24 health facilities in 2 regions in Northern Tanzania.
The specific Population included Pediatrics – children under 15y/o admitted to ped / adult wards only.
The health facilities varied from District hospital level to Disp level.

7. Aim Statements
Increase pediatric inpatient PITC rate to 80% or higher by March 2016.
Increase the linkage of HIV-positive children from testing to enrollment in care and treatment to 90% or higher by March 2016.
The planning phase began in Dec 2014 and learning session implementation began in May 2015
Aim statement were selected by the NACP which had a national target for PITC performance that 80% of inpatient admissions should be offered an HIV test

8. Implementation: Learning Session Team Presentations
We supported a total of 4 learning sessions over 11 months where teams presented their data and implementation activities with each other in detail.

9. Testing Site-level Innovations
QI teams at each site developed and tested interventions (“change ideas”) aimed at improving systems and processes
Ideas were systematically prioritized and underwent rapid, iterative tests of change
Standardized approaches to data collection and DQA were used at all sites
Ongoing site-level QI coaching was provided by local implementing partners with ICAP support
In between learning sessions, QI teams at each site developed and tested interventions (“change ideas”) aimed at improving systems and processes

10. Quarterly QI Mentoring Visits
Ongoing site-level QI coaching was provided monthy by moh and local implementing partners with ICAP support

11. Facility Run Chart Documentation Measuring Changes
This is an example of one facilities documentation process where they note their change ideas tested and measuring their indicator data using run charts.

12. Successful Change Ideas – 1
Facility teams identified 27 successful change ideas in the following domains:
Staff education
Staffing matrix
Work flow processes
Commodity management
Documentation
Patient education
Referral processes
Facility teams ultimately identified 27 successful change ideas and these were categorized the following domains:
Staff education
Staffing matrix
Work flow processes
Commodity management
Documentation
Patient education
Referral processes

13. Successful Change Ideas – 2
Including Peds PITC testing in shift handover reports
Using checklist to identify admitted and tested patients to hand to next shift
Handover report to include files of children not yet tested
Daily monitoring of Peds PITC during clinical rounds
Assign Peds PITC target for each shift
Mark all Peds IPD files (sticker) who receive PITC
Written reminders at nursing station
Internal weekly supportive supervision visits to IPD
“No child discharged without knowing HIV status” hospital campaign
Some of the more innovative locally driven change interventions included things like:
Including Peds PITC testing in shift handover reports
Using checklist to identify admitted and tested patients to hand to next shift
Handover report to include files of children not yet tested
Written reminders at nursing station
“No child discharged without knowing HIV status” hospital campaign

14. Preparation Phase and baseline data Jan to Apr 2015 Joint QI Visits
LS2 in Aug 2015
QIC Target
Joint QI Visits
Oct 2015
Joint QI Visits
July 2015
LS3 in Nov 2015
Final Stakeholders meeting in Mar 2016
This annotated run chart demonstrates improvement in two important indicators
Inpatient children receiving PITC in blue line
Rapid test kit stock outs in red line
Jan through April is the planning phase and baseline data collection
The chart is annotated with key activities of the QIC such as the learning sessions and supportive supervision visits.
As you can see here, that despite the great improvements in testing sites were also able to reduce test kit stockouts.
RTK national stock out Mar to Apr 2015

15. Percent of children newly enrolled in care at all 24 participating QIC sites
QIC Target
This data shows the second aim to ensure linkage from testing to enrollment in care.
And Also despite the increased burden of testing and need for a strong linkage system, linkage remained high throughout the life of the QIC.

16. Results
A total of 16,569 of 25,282 children (66%) admitted during the 11 months intervention period received PITC (May 2015 to March 2016)
263 (1.6%) tested HIV+, and 255 (97%) enrolled in care.
Improvements in commodity management reduced the average number of test kits stock out days from 8.8 to 1.5 days/month.
Improvement was rapid
Average time for sites to achieve AIM 1 = 2.5 months (median 3.0)
Improvement was sustained
On average, sites achieved AIM 1 for 5.2 months

17. Conclusions
QI collaborative resulted in increase in HIV testing of pediatric inpatients
Linkage rates remained high
All sites demonstrated active participation in QIC and tested many change ideas
Sites improved test kit supply management and reduced test kit stock outs while testing increasing numbers of children
Further follow-up needed to determine sustainability of the effect
In conclusion, we believe that using the QI collaborative approach resulted in increase in HIV testing of pediatric inpatients
All sites demonstrated active participation in QIC and tested many change ideas
Sites improved test kit supply management and reduced test kit stock outs while testing increasing numbers of children
And Lastly,
Further follow-up needed to determine sustainability of the effect

18. Acknowledgements
We would like to express our sincerest gratitude to the Tanzania MOH and the National AIDS Control Program (NACP), the 24 participating health facility QI team participants and to the Ariel Glaser Pediatric AIDS Healthcare Initiative (AGPAHI) and the Christian Social Services Commission (CSSC) partners.
This project was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention under the terms of awards 5U2GPS and 5U2GGH
The contents are the responsibility of ICAP and do not necessarily reflect the views of the United States Government
To conclude my presentation, I would like to express our sincerest gratitude to the Tanzania MOH and the National AIDS Control Program (NACP), the 24 participating health facility QI team participants and to the Ariel Glaser Pediatric AIDS Healthcare Initiative (AGPAHI) and the Christian Social Services Commission (CSSC) partners.