Building on the results of a quality-of-care assessment of the ART continuum-of-care system and initial

quality improvement (QI) activities started with FY07 plus-up funds, URC/QAP will continue the rapid scale-

up of QI activities and improvement of the HIV/AIDS treatment and care system, processes, and outcomes

and the overall quality of the family-centered treatment approach.

In FY07, URC/QAP is carrying out a detailed assessment of ART services across the continuum of care at

all national ART sites. This includes evaluating palliative care, PMTCT, CT, ART (including pediatric ART),

and HIV/TB services and the efficiency of resource use. Important issues in the system of care and in the

processes of care are being studied and analyzed, including providers' understanding of and compliance

with national standards of care, barriers to providers' complying with standards of care, access to and

quality control of laboratories (both referral and at facilities), drug and lab supply stockouts and supervision,

and patient compliance and adherence to therapy. By reviewing medical records and through interviews,

URC/QAP is also following selected patients to understand the difficulties they have in negotiating the

system and accessing timely services. URC/QAP has extensive experience in conducting quality-of-care

assessments, including HIV/AIDS services in such countries as South Africa, Rwanda, Uganda, Tanzania,

and Jamaica.

Using the assessment as a basis, URC/QAP will engage the government of Cote d'Ivoire and other partners

in determining the best way to rapidly solve the problems identified and build a sustainable quality control

and quality improvement system for ART and other HIV/AIDS services. Quality of care committees (or

subcommittees of existing oversight groups) will be organized at national, regional, and district levels.

Selected staff will be trained in QI approaches, coaching and mentoring of facilities, quality monitoring, and

implementing selected QI approaches.

While URC/QAP will support implementation of any QI approach selected, it has extensive experience with

the improvement collaborative approach, which was developed by the Institute for Healthcare Improvement

(IHI) in Boston and is in widespread use in Western countries. URC/QAP has led the way in its use in 15

developing countries, including six PEPFAR focus countries. It consists of an organized network of a large

number of sites (districts, facilities, or communities) that work together for a limited period of time, usually

nine to 24 months, to achieve significant improvements in a focused topic area, such as ART services,

through shared learning and intentional spread methods. URC/QAP has helped countries to achieve

dramatic results in a short period of time, including in the outcomes of care.

With FY07 funds, such a QI approach will be launched to rapidly scale up a quality assurance approach at

all ART sites. This approach is expected to achieve significant improvements in compliance with standards

and patient adherence, retention, and follow-up along the continuum of care.

With FY08 funds, URC/QAP will:

1. Continue to assist the national program and stakeholders to build the ART system's QI structure,

functions, and capacity

2. Continue to assist the national program to strengthen its process for updating guidelines and key

indicators for monitoring quality of care

3. Continue to assure, revise, and adapt monitoring tools for self-assessment by facilities and other service

providers, and for coaches

4. Continue to develop regional and district QI structure, functions, and capacity through training, mentoring,

involvement in learning sessions, and coaching visits

5. Continue to assist the national program and partners in the implementation of the ART QI approach at all

sites. This will include:

• Learning sessions, during which site representatives present their challenges and results, share key

indicator data, and receive technical updates and refresher training in quality improvement

• Action periods, during which site quality-improvement teams identify problems, select changes to test, self-

assess, report results achieved monthly, and confer with coaches, who visit sites once a month

• A national conference/workshop

6. Assist the national program to develop a sustainability plan for the continuation of QI activities

7. Assist the national program to prepare a report on the QI activities.

Expected results include:

1. National, regional, and district QI capacity developed, i.e. managers and staff assure updating of

guidelines for care and key indicators of quality. They also continue to assess the quality of ART care,

coach site QI teams, assure validity of data, set priorities, provide resources, and reward good performance

2. Completion of the first ART system QI effort involving all ART sites, with dramatic improvements in quality

of care as measured by key input, process, and outcome indicators

3. QI sustainability plan developed and implementation started

4. National conference on improving ART care held and results of QI efforts presented. Sustainability plan

discussed and approved

5. Report of QI activities published

6. Ivorian counterparts present results at an international forum.