Spotlight: Champasak Hospital

Linking stigma-reduction QI activities to UNAIDS’ 90-90-90 targets and national quality policies at Champasak Provincial Hospital, Lao PDR

Background

Champasak Provincial Hospital is a tertiary facility located in Pakse—

approximately 460 km south of Vientiane, Lao PDR’s capital (pictured, right). The PEPFAR-supported ART clinic at Champasak is one of 11 sites that delivers HIV care in the country. As of 2017, it provides ART services to over 600 people living with HIV (PLWH), placing it among the highest burden sites in Lao PDR. In 2018, the hospital was selected by Lao PDR’s Center for HIV/AIDS/STIs (CHAS) to participate in a nationwide initiative to apply quality improvement (QI) methods to the reduction of HIV-related stigma and discrimination (S+D). As part of these activities, the hospital partnered with CHAS QI coaches and UCSF-HEALTHQUAL to develop a facility-wide plan for reducing HIV-related S+D and improving the quality of care for PLWH.

Stigma-Reduction QI Activities

Following a national S+D QI orientation workshop in August 2018, Champasak Hospital staff were instructed by
CHAS to develop a work plan for implementation of S+D reduction activities as part of ongoing QI efforts. In its plan, hospital staff identified four key pillars for success: organization, measurement, improvement, and integration.

Organization
To guarantee that S+D reduction QI activities are implemented in all service areas where PLWH seek care, the ART clinic team engaged the hospital’s quality committee as a first step. In response to the ART clinic staff’s request, a multi-disciplinary S+D sub-committee was created, with the hospital’s Deputy Director serving as Chair, and members of the ART clinic’s QI team serving as representatives. The objective of the sub-committee is to ensure S+D are addressed as part of the hospital’s approach to quality. The sub-committee meets quarterly, and report to the hospital’s quality committee on implementation progress.

Measurement
With guidance from CHAS, the Champasak Hospital team plans to measure HIV-related S+D on a quarterly basis using a web-based survey platform (REDCap) and 8 common indicators. To ensure that all service areas are engaged, the hospital team has committed to surveying all staff. As of November 2018, one round of survey collection has been completed, with the second round planned for January 2019. To supplement insights from survey findings, the team will routinely collect data on patient experience using comment boxes, self-help groups, and clinical encounters to identify areas for improvement.

Improvement
Findings from the initial round of data collection among healthcare workers revealed gaps in provider knowledge about HIV transmission (particularly among pregnant women), and some evidence of negative attitudes toward PLWH. Moreover, findings also revealed providers’ uncertainty about existing policies related to stigma and discrimination. Finally, feedback from patients obtained through comment boxes showed staff communication to be the most common complaint. To address these gaps, the hospital team will test several interventions using Plan-Do-Study Act (PDSA) methodology (Table 1). QI implementation will be monitored by the S+D sub-committee, with QI coaching support provided by CHAS technical staff on an ongoing basis.

Table 1. QI Interventions

Integration
To ensure the integration of S+D QI activities with national initiatives, th​e hospital has made explicit linkages among stigma reduction activities, achievement of UNAIDS’ 90-90-90 targets, and the Lao national framework for healthcare quality—Five Goods, One Satisfaction. Compliance with Five Goods, One Satisfaction is mandatory for all health facilities in Lao PDR, and hospital leadership are required to report on implementation of quality activities to the Ministry of Health on a routine basis. Through clear signage in the entry of the ART clinic (pictured, right), both healthcare workers and PLWH are reminded that achievement of UNAIDS targets are achieved through high performance in the six national HIV QI indicators and strong adherence to the national quality policy. This means ensuring that the content of the care delivered—and the environment in which it is delivered—are consistent with national guidelines, respond to the needs (i.e., satisfaction) of patients, and address common barriers to accessing ART, such as real and perceived S+D.

Lessons Learned
Through thoughtfully planned organization, measurement, improvement, and integration, Champasak Provincial Hospital aims to improve the lives of PLWH by creating a welcoming clinic environment that is free of stigma and discrimination. In its approach to planning, the hospital team has adopted several ”best practices” that are crucial to the success of S+D reduction activities in particular, and to QI activities in general.

• Early and active engagement of hospital leadership. PLWH do not only receive services related to their HIV diagnosis, and may therefore experience S+D outside of the ART clinic. Early engagement of hospital leadership in S+D QI activities ensures that the response is hospital-wide and reaches all service areas where S+D may exist. Early engagement is also an effective strategy for building facility-wide accountability and securing human and material resources for S+D reduction activities when they are available.
• Commitment to routine (quarterly) measurement of S+D. When they are relevant, timely, and location-specific, data are a powerful enabler of behavior change and quality improvement. However, to guarantee that interventions work— and that improvements are sustained over time—measurement cannot be a one-time activity; it must be routine.
• Proactive collection and use of varied data on patient experience. Promptly and appropriately responding to the needs and preferences of patients is an activity that all high-quality health systems do well. A blended approach in which data on patient experience are gathered through multiple modalities (e.g., comment boxes, self-help groups, clinical encounters, structured surveys) ensures data are representative and actionable. Data on patient experience should seek to answer three interrelated questions during each visit: (1) What are patients’ care needs? (2) Are these identified needs being met? And (3) if they are not being met, what can be done to ensure that they are met during future visits?
• Linkage of S+D QI activities to 90-90-90 targets and national quality policies. Transparently relating S+D QI activities to achievement of national and international targets and policies offers a shared vision and approach that can be leveraged to generate stakeholder buy-in, secure human and material resources, and prevent duplication of efforts.

Acknowledgements
In its production of this Spotlight, UCSF-HEALTHQUAL thanks the staff of Champasak Provincial Hospital and the Center for HIV/AIDS/STIs for their contributions and careful review, and to Chiang Mai University for its ongoing technical support. The Southeast Asia Stigma Reduction QI Learning Network is supported by the U.S. President’s Emergency Plan for AIDS Relief as part of the Health Resources and Services Administration’s (HRSA) Quality Improvement Capacity for Impact Project (QICIP). The contents are the responsibility of UCSF-HEALTHQUAL and do not necessarily reflect the views of the U.S. Government.