CARE THAT COUNTS The Quality Improvement Initiative for OVC

CARE THAT COUNTS: The Quality Improvement Initiative for OVC Programs Lynne FRANCO ; Renee DE MARCO ; DeeDee YATES ; Lucy STEINITZ ; Kate HARRISON ; Jane CALDER ; Gretchen BACHMAN ; Lori DIPRETE BROWN ; Marie-Eve HAMMINK 1 2 3 4 5 6 4 1 1 1 University Research Co., LLC (Health Care Improvement Project); 2 United States Agency for International Development; 3 Independent consultant; 4 Family Health International; 5 International HIV/AIDS Alliance; 6 PACT Challenges to Implementation In response to the growing number of children affected by HIV/AIDS, efforts to provide services for orphans and vulnerable children (OVC) have expanded rapidly. However, implementers and donors are asking themselves about the impact and quality of the care they are providing. Quick response to the havoc of the HIV/AIDS epidemic has led donors and implementers to focus most of their efforts on providing very rapid and high coverage responses, without really knowing if such efforts were truly making a difference in the child’s life. OVC Programs often focus on activities or outputs rather than desired outcomes Example: Education Services What is Quality of Care for OVC Programs? Quality care implies an appropriate mix of services and support to children, families and communities to ensure that children affected by HIV and AIDS grow and develop as valued members of their families and community, including food and nutrition support, shelter and care, protection, health care, psychosocial support, education and vocational training, protection, and economic opportunity. The variation in and lack of equity among OVC service providers on what constitutes “an OVC served” indicates a need to define and achieve quality. How can we ensure these services are effective, efficient, and equitable? Bought and distributed backpacks 1,500 OVC received backpacks Child is enrolled in and regularly attends school The Response:The Quality Improvement Initiative for OVC Programs The Quality Improvement Initiative for OVC Programs is a new partnership that brings together USG, national governments and civil society OVC implementing partners in many countries to use quality improvement (QI) approaches for establishing and applying OVC service standards. Activities under the QI Initiative include capacity building events, communication mechanisms and technical assistance to countries and implementing partners in developing service standards, monitoring and improving the quality of care provided to OVCs. Over time, the QI Initiative seeks to develop a cadre of regional champions and an African-based Partnership for Quality of OVC programs. and providing guidelines on how to achieve service standards help those on the front line to provide care that can foster movement towards the desired outcomes. Service standards alone will accomplish little if they are not used as a guide for both measuring quality and improving quality— where service providers use data to identify changes in how they provide OVC services (and support OVC service provision) that would improve their ability to reach the desired outcomes. Defining Quality: Example of One Standard Service: PSYCHOSOCIAL SUPPORT Measurable Goals (from the Child Status Index): • Emotional Health: The child his happy and content and has a generally positive attitude. • The child is cooperative and enjoys participating in activities with other children and adults. Essential Actions that define this service: • Strengthen family ability to support emotional and social development of children and adolescents. Defining Quality Dimensions of Quality for OVC Services • Safety • Access • Effectiveness • Technical performance • Efficiency • Continuity • Compassionate relations • Appropriateness • Participation • Sustainability • Build the capacity of communities (friends, neighbors, places of worship, schools, etc.) to provide emotional and social support to children and adolescents and their caretakers. Desired Outcomes Example of a Desired Outcome • Provide monitoring, referral and follow up for children and adolescents needing counseling by professionals or para-professionals, or other psychosocial support services. • Promote ethical practices for all who work with children so that care is appropriate in terms of gender, age, and special needs, an so that equity of care, safety concerns, and continuity of care are safeguarded. How can we improve the quality of OVC services? How can our programs make a measurable difference in a child and family’s lives? Quality Improvement offers a way to organize and harmonize the provision of care by engaging people at the point of service delivery to reflect and improve on the quality of care. The quality triangle provides a frame for improving quality—and at its core is the desired outcome (with explicit youth input in its definition): What measurable difference in the lives of children do our programs need to achieve? The enormous variation among implementing partners indicates that defining quality is a key next step for OVC programs. Reflecting on dimensions of quality, identifying essential minimum actions for each service delivery area OVC service providers meet to discuss current service processes and changes they can make to improve care for children. “Children will have the human attachments necessary for normal development and participate cooperatively in school, recreation, family settings and work with other children and adults” Illustrative composite standard for Psychosocial Support Youth participants at a 2007 workshop in Zimbabwe discuss their desired outcomes, which became the frame for the subsequent standards development workshop Children will make more friends and build up self-confidence. “With psychosocial support, we might become responsible leaders.” “We will have a positive image of ourselves and our future.” Children participating in youth workshop in Namibia 2007 Improving Quality Improving Quality Improving quality includes all efforts to do a better job of achieving the desired outcome for children, and at the same time enhancing the efficiency and reach of services and programs. In the past, efforts to improve quality often focused almost exclusively on developing standards and doing training. However, experience in recent years has shown the power of strategies such as supportive supervision, team-based process improvement, improvement collaboratives, and communities of practice. Quality improvement relies on teamwork to examine systems and processes. Teams within and across the range of service providers use standards to reflect on their current activities and process. Teams then test options for implementing changes. Innovation is highly encouraged. Team exchanges can strengthen the learning process and often generate consensus on best practices. Aspect of reflection Are teams following the standards? If the standards are followed, do they ensure quality of the OVC program? Measuring Quality Measuring Quality Type of data Adherence to standards Possible data sources Supervision checklists based on observation and discussion • Program performance with respect Discussion and internal to the dimensions of quality reflection; Interviews with children, caretakers, other • Client satisfaction stakeholders • Outputs Outcomes Child Status Index or other tools If standards are followed, do the children being served fare better? What Has Been Accomplished So Far? n Future Directions The ultimate goal of the Initiative is to establish an African-based Partnership for Quality in OVC Programs to promote quality in OVC programs through advocacy, capacity building, mentoring and coaching, regional sharing events, and dissemination of best practices. Next steps include gathering lessons learned from related regional networks/ partnerships, forming an executive group to guide the Partnership’s development, and continuing the dialogue with stakeholders, including government ministries and donors, on what they would like to see as the Partnership’s mission and objectives. Facilitator’s guide to establishing service standards for improving quality of OVC services Support to government and implementing partners in Ethiopia, Namibia, Uganda, Tanzania, and Zimbabwe to develop draft service standards Networking through monthly “Quality in Focus” conference calls— recent topics: Moving Standards to the Field (Jan 08), Coordination of Care (Feb 08), Supportive Supervision (Mar 08), Improvement Collaboratives (April 08) Quality Improvement section on the OVC Support Toolkit web site: www.ovcsupport.net/qi (to be operational in June 2008) Capacity building: Supporting standards-based quality for the care of orphans and vulnerable children (Washington, DC, April 26, 2008, 50 participants) Improving and assuring quality services for orphans and other vulnerable children (Tanzania, September 10–14, 2007, 50 participants from 15 African countries) Care that Counts: Improving the Quality of OVC Programs (Washington DC, April 9-10, 2008, 25 OVC taskforce members participating) n n n Acknowledgements The work was supported by the USAID Health Care Improvement Project (HCI) and its predecessor, the Quality Assurance Project (QAP), managed by University Research Co., LLC (URC). Funding support was provided by the American people through the United States Agency for International Development (USAID) under Contract Number GHN-I-01-07-00003-00. For more information on the QI Initiative for OVC Programs, contact Lynne Franco (lfranco@urc-chs.com) or Marie-Eve Hammink (mhammink@urc-chs.com). n n Support to Ethiopia and Tanzania with several implementers to develop an improvement collaborative for OVC services