Quality and Quality Improvement
CQUIN focuses on both differentiated service delivery (DSD) coverage and quality. The CQUIN Dashboard tracks DSD coverage in network countries, all of which have shown notable progress in expanding geographic coverage and the proportion of eligible people enrolled in differentiated ART (DART) models. The dashboard also tracks quality – and most network countries have progressed more slowly in this domain, largely due to lack of data about DSD program quality. However, programmatic experience highlights the need for close attention to DSD quality challenges including imperfect use of DSD eligibility criteria; suboptimal utilization of viral load data; changes to program design that discourage enrollment; and lack of fidelity to DSD guidelines.
In response, CQUIN launched a community of practice focused on DSD-related quality and quality improvement, engaging network participants in a series of in-person workshops and an ongoing virtual collaboration. In June 2019, CQUIN hosted an all-network workshop on DSD Quality and QI, and the network continues to explore each of the three elements of the classic “Juran Triad” as they relate to DSD – quality planning, quality assurance, and quality improvement. In 2020, the community of practice reacted to the lack of global and national quality standards for DSD by co-creating a DSD quality standards framework for less-intensive DART models.
In 2021, the CQUIN Quality and QI Community of practice has developed and piloted quality standards for DART models toolkit in three countries. The tool is intended to serve as a complementary resource for stakeholders to assess and improve DART quality. It is envisioned to be a living document and feedback and suggested edits or additions are always welcome. Each country should feel free to adapt the tool to the local context and DART models.
Quality planning asks: “What is the quality standard?” and establishes goals and targets for health system performance. While all CQUIN Network partner countries have national DSD policies and guidelines, and many have targets for DSD coverage, fewer have specific standards for DSD quality. The CQUIN Quality & QI community of practice has developed a DSD quality standards framework for less-intensive DSD treatment models and is working on relevant indicators for countries and programs to adapt to their local contexts.
Quality assurance asks: “Are we meeting the standard?” and measures performance against targets. The CQUIN Quality and QI community of practice continues to explore different countries’ approaches to DSD-specific QA (including related indicators and data sources) and the extent to which their growing DSD programs meet quality standards. In 2021, the community of practice will develop and pilot quality standards for DART models.
Quality improvement asks: “How can we continuously improve performance?” Key elements include identification of a quality challenge, root cause analysis, identification and prioritization of interventions, selection of indicators, and rapid, iterative tests of change. CQUIN has conducted a series of workshops and trainings on QI-for-DSD, and the Quality & QI community of practice continues to exchange updates, outcomes, and resources related to QI-for-DSD projects. ICAP’s CQUIN team will also continue to provide training and capacity building related to QI-for-DSD in 2021.