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Кyiv2017

Clinical Assessment for Systems Strengthening (ClASS)2

This publication presents information on CIASS (Clinical Assessment for Systems Strengthening)launched in Ukraine in 2012 upon joint initiative by the International Training and Education Center forHealth of the University of Washington (I-TECH/UW) and the Public Health Center of the MOH ofUkraine as a quality assessment tool to develop the capacity of health care facilities in Ukraine. Itoutlines success stories on implementation of recommendations by the facilities where CIASSassessment was conducted in 2014-2016.

It could be of interest to the managers and specialists of the health care facilities of all levels,programs and projects of international technical assistance, and non-governmental organizations workingin the area of HIV/AIDS prevention and treatment in Ukraine.

International Training and Education Center for Health of theUniversity of Washington, 2017

©

3Success Stories and Best Practices in Ukraine

ABSTRACT

This publication presents information on CIASS (Clinical Assessment for SystemsStrengthening), a quality assessment tool to develop the capacity of health carefacilities in Ukraine, and provides examples of successful implementation ofrecommendations by the facilities where CIASS assessment was conducted in2014-2016.

The authors hope that this publication will contribute to the:

• Improvement of national, regional, and local level stakeholders’ understandingof the importance and benefits of CIASS as a tool for health care facilitiescapacity building and a basis for continuous quality improvement developmentin a particular facility;

• Dissemination of best practices described in this publication at the national andlocal levels;

• Enhancement of interest among health care facility administrators in Ukrainefor quality assessment of organizational capacity of relevant facilities andorganizations.

This publication may be useful for managers and specialists of health care facilitiesof all levels, technical assistance programs and projects, and non-governmentalorganizations working in the area of HIV/AIDS prevention and treatment in Ukraine.


AUTHORS

Deputy Director General for Coordination of ProgramActivities and Strategic Development, Public Health Centerof the MOH of Ukraine, [email protected]

Coordinator of ClASS Implementation in Ukraine, PublicHealth Center of the MOH of Ukraine, [email protected]

Country Representative, I-TECH Ukraine, InternationalTraining and Education Center for Health of the Universityof Washington, [email protected]

Program Director, I-TECH Ukraine, International Trainingand Education Center for Health of the University ofWashington, [email protected]

Training Developer, I-TECH Ukraine, International Trainingand Education Center for Health of the University ofWashington, [email protected]

Ihor Kuzin

Vira Yatsyk

Anna Shapoval

Iryna Yuryeva

Tetiana Bairachna


The Public Health Center of the MOH of Ukraine and the Ukraine Office ofInternational Training and Education Center for Health (I-TECH) of the University ofWashington express their gratitude to:

• International CIASS expert Stephen R. Collens for developing the structure forthis publication;

• Representatives of health care facilities who provided information and photosfor this publication.

CIASS assessment and this publication were made possible with the supportprovided by the Health Resources and Services Administration (HRSA) of the U.S.Department of Health and Human Services (HHS) funded with U91HA06801 grantto the International Training and Education Center for Health. This information/ contentand conclusions are those of the author(s) and should not be construed as the officialposition, policy or positive feedback of HRSA, HHS or the U.S. government.

ACKNOWLEDGEMENTS


ABBREVIATIONS AND ACRONYMS

ART Antiretroviral therapy

HIV Human immunodeficiency virus

OST Opioid substitution therapy

PLHIV People living with HIV

ICF International Charitable Foundation

M&E Monitoring and evaluation

MOH Ministry of Health

AIDS Acquired immune deficiency syndrome

TB Tuberculosis

CIASS Clinical Assessment for Systems Strengthening

I�TECH International Training and Education Center for Health


CONTENTS

Introduction

Improvement of access to HIV services for high-risk groups inmobile laboratory setting in Kyiv Oblast

Providing computer equipment to Kryvyi Rih AIDS CenterMonitoring and Evaluation Department specialists

Launching a new Trust Room to improve access to health careservices for HIV-positive patients in Poltava Oblast

Improvement of access to treatment services (ART) for TB/HIVco-infection patients in Cherkasy Oblast

Setting up periodic training courses on the quality of pre-testcounseling and completing record and reporting documentationfor infectious disease doctors in Chernivtsi Oblast

Decentralization of HIV services in Chernihiv Oblast

Conclusions

12

17

21

26

32

37

42

8


INTRODUCTION

Reforming the Ukraine health care system in terms of care provision decentralizationand services quality and access improvement requires introducing new strategies,approaches and tools at both national and regional level.

One such tool is the CIASS quality assessment - Clinical Assessment for SystemsStrengthening – developed by the International Training and Education Center forHealth of the University of Washington (I-TECH/UW). In Ukraine, the ClASS techniqueis adapted and implemented by the Public Health Center of the MOH of Ukraine withfinancial support from I-TECH. The ClASS technique is designed to strengthencapacity and increase the efficiency of a particular health care facility, improve thequality of health care services and the health care system, as well as to ensurecontinuous enhancement of this system.

The major purposes of conducting ClASS are:

• To identify best practices and achievements that can be implemented into otherhealth care facilities;

• To single out areas requiring improvement;

• To seek means of providing sustainable continuous services and expandingtheir range and scope.

Unlike auditing or inspection tools, the ClASS technique does not entailidentification of gaps in the work of a particular specialist or facility. Instead,assessment results help to identify well-functioning facility systems, proceduresand processes (strengths); list unavailable or imperfect regulatory documents,systems, procedures or processes and determine their direct impact on the qualityof services provided by the facility (areas for improvement); and prepare soundrecommendations regarding specific steps to be taken while working with eacharea for improvement.


The ClASS assessment process consists ofsix stages:

• Initiation (directly by the health care facilityor Public Health Center of the MOH ofUkraine);

• Preparation for CIASS;

• Assessment;

• Action planning based on the results of theCIASS assessment. The results of thisstage are reflected in an Action Planprepared by the facility specialists,designed for the implementation ofreceived recommendations;

• Preparation of the CIASS assessmentreport.

Once the assessment cycle is completed, theAction Plan stage with focus on recommen-dations implementation begins.

In Ukraine, unlike in other countries whereCIASS is implemented, an officially approvedfinal stage of assessment cycle includes initiationof a Continuous Quality Improvement of servicesprovided by the health care facility where theassessment was conducted.

The ClASS tool is comprised of modulespresented as topic-specific guides for qualityassessment of facilities through in-depth groupand individual interviews, reviewing keydocuments, and verifying information. The MOHof Ukraine has officially recommended the use

of the Administrative Module, Financial Module,HIV Counseling and Testing (HCT) Module, andthe Clinical Module. In 2016-2017, a LaboratoryModule and TB/HIV Co-infection IntegratedServices Module were additionally developed.

CIASS implementation in Ukraine started in2013. In 2013-2017, the Public Health Center ofthe MOH of Ukraine supported by I-TECH:1) trained twenty two certified national reviewers/experts to conduct ClASS; 2) developed theGuidelines “Using the Clinical Assessment forSystems Strengthening (ClASS) Technique forMonitoring the HIV/AIDS Response at UkrainianHealth Care Facilities” (registration No. 177.15/04/16b of January 28, 2016) and received MOHapproval for it; 3) conducted ClASS assessmentin 13 AIDS Centers, 5 TB Dispensaries, 7 TrustRooms, and 2 non-governmental organizationsin 20 regions of Ukraine.

In Ukraine, unlike in other countries where thefinal ClASS stage is Action Plan development,in 2016-2017 visits were made to previouslyassessed facilities – in Kryvyi Rih City, Chernivtsi,Cherkasy and Kyiv Oblast AIDS Centers – tomonitor the recommendations implementation.The analysis of Action Plan implementationconducted during these visits helped to singleout a number of best practices and specific stepstoward strengthening the facility capacity,organizational capability, and qualityimprovement of provided services.

10 Clinical Assessment for Systems Strengthening (ClASS)

ClASS assessments geography in 2013�2017(dark green)


In addition, in February and June 2017,meetings for national level specialists were heldduring which representatives of the facilities thatparticipated in the assessment had a chance toexchange their experience with Action Planscompletion and provided specific successfulexamples of expert recommendationsimplementation. The participants of the meetingsagreed that dissemination of the best practices(i.e. success stories), indicative of CIASS positiveimpact on assessed facility capacity streng-thening through the Action Plan implementation,would promote more active and effectiveadoption of this technique in Ukraine.

Success stories were selected to representall CIASS modules and reflect geographicalvariety of health care facilities.

To unify the information collected andanalyzed, each story has the following structure:

• Success story category by relevant ClASSModule;

• Health care facility that made theimprovement;

• Issue (area for improvement) identifiedduring the assessment;

• Implemented improvement initiative;

• Key results of the improvement initiative;

• Overall impact of the implementedimprovement initiative;

• Unique experience gained by the healthcare facility;

• Statements and feedback of represen-tatives of the health care facility that madethe improvement;

• Information about partners involved in theimprovement initiative;

• Contacts for more information regarding asuccess story.


Success story category by relevant ClASSModule: HIV Counseling and Testing

Health care facility that made theimprovement: Kyiv Oblast AIDS Center

Issue (area for improvement)identified during the assessment:

When the ClASS assessment was conductedin Kyiv Oblast AIDS Center (April 2016), HIVtesting of high-risk group representatives in KyivOblast remained at a rather low level (based onseroepidemiologic monitoring data, the share ofsuch groups in the total number of people testedfor HIV was only 9% in 2015).

The issue had several causes:

• Remoteness of health care facilities thatprovided quality health care services,including HIV counseling and testing, fromplaces of residence or gathering of high-risk groups;

• Not all rayons of the oblast were coveredby services of non-governmental organi-zations (in particular, by case managementservices);

• Limited number of ART sites. When theCIASS assessment was conducted therewere only 12 fully functioning ART sitesproviding HIV services to the population inthe central rayon and city hospitals.Residents of twenty other rayons of theoblast, including high-risk group

ClASS SUCCESS STORY:

IMPROVEMENT OF ACCESSTO HIV SERVICES FOR HIGH�RISK GROUPS IN MOBILEAMBULATORY SETTINGIN KYIV OBLAST


representatives, received health careservices in Kyiv Oblast AIDS Center or, incase of TB diagnosis, in the Oblast TBFacility;

• In Kyiv Oblast AIDS Center, square metersand number of available premises failed toprovide enough working and confidentialspace in cases when large numbers ofpatients visited the facility from rayons andcities of the oblast. This led to unfavorablework conditions for the infectious diseasedoctors and for the counselor in particular,as well as to decline of health care efficacy.

Based on ClASS results, experts conductingthe assessment provided the followingrecommendations regarding the HIV Counselingand Testing Module:

• Improve access and engage high-riskgroups in HIV counseling and testing byraising awareness and strengthening thecooperation with non-governmentalorganizations taking preventive measuresin locations where high-risk groups arerepresented;

• Improve the organization and methodo-logical work of the Kyiv Oblast AIDS Centerby focusing on the need to actively involvehigh risk group representatives to testing;

• Coordinate the activities of non-govern-mental organizations to improve thecoverage of high-risk group representativesthrough HIV testing.

Improvement initiative and its keyresults

According to the provided recommendations,Kyiv Oblast AIDS Center developed an ActionPlan. To implement it, the facility administration,subject to agreement with the Kyiv Oblast StateDepartment, established a Mobile Testing Unitwith five full-time staff positions: Head, InfectiousDisease Doctor, Nurse, Social Worker, andDriver.

Provision of quality HIV counseling and testingservices on the route of the newly establishedMobile Testing Unit required a vehicle. Thus, theAIDS Center Administration signed an agreementwith ICF “Alliance for Public Health” that provideda special medical vehicle (mobile ambulatory) forthe AIDS Center to conduct counseling, testing,and early linkage of HIV-positive patients;improve access to integrated services for patientsin need of such services; ensure continuouslinkage between testing and treatment services;and organize clinical mentoring and organi-zational and methodological support of medicalstaff and local team members of health carefacilities in Kyiv Oblast (city hospitals, centralrayon hospitals, and primary health care centers).


Overall impact of the implementedimprovement initiative

The mobile ambulatory helped to maximizethe access to multiple integrated HIV services:counseling, bringing patients to the Trust Roomsand for medical monitoring as soon as possible,developing ART adherence, and conducting TBscreening (using GeneXpert) and CD4 laboratorytesting with PIMA portable CD4 counter machine.

In addition, the mobile ambulatory allows formentorship visits during which Kyiv Oblast AIDSCenter specialists provide consultations oncomplicated clinical cases, conduct workshopson HIV counseling and rapid testing for staff ofprimary health care centers, etc.

Within the framework of the mobile ambulatoryoperations, the facility was able to begin activecooperation with non-governmental organi-zations providing HIV counseling and testingservices to high-risk group clients andimplementing harm reduction programs, etc.

As of June 1, 2017, mobile unit utilization ratewas at 90%. According to the Kyiv Oblast AIDSCenter M&E Department, from February to May2017, 250 people received HIV counseling andtesting services through the mobile ambulatory,21 of whom were identified HIV positive (8.4%).

Because of improved access to HIV servicesthrough the mobile ambulatory, in 2017, thecoverage for most-at-risk patient groups throughcounseling and testing services, as well as

bridging gaps between the estimated number ofpeople living with HIV and the number of peopleaware of their HIV-positive status are expectedto improve.

Unique experience gained by thehealth care facility

ClASS health care facility assessment helpedKyiv Oblast AIDS Center to:

• Find solutions for issues using the ActionPlan (Mobile Testing Unit);

• Combine facility resources and efforts withthose of other organizations to fully resolvethe identified issue;

• Engage available Kyiv Oblast AIDS Centercapabilities and resources to resolve theissue.

Statements and feedback ofrepresentatives of the health carefacility that made the improvement

Oksana Holub, Director of Kyiv Oblast AIDSCenter:

“Since in the Oblast there was an issue relatedto the remoteness of medical monitoring and ARTservices for PLHIV living in the Oblast areasremote from the AIDS Center, ClASSassessment helped to find an optimal solutionfor this issue through the mobile ambulatoryintroduction within a short time. Visits of the


Photo: Mobile ambulatory provided to Kyiv Oblast AIDSCenter as a result of CIASS assessment Action Plan

implementation


mobile ambulatory to the Oblast areas with noART sites provide patients with an opportunityto receive timely HIV services at the place of theirresidence”.

Anastasia Ostapenko, Kyiv Oblast AIDSCenter Trust Room Counselor:

“While participating in the CIASS facilityassessment, I was able to see with my own eyesthe implementation of ideas to improve the qualityof HIV counseling and testing services in KyivOblast!»

Information about partnersinvolved in the improvementinitiative:

• ICF “Alliance for Public Health”

Contact person for moreinformation regarding thissuccess story:

Oksana Holub, Director of Kyiv OblastAIDS Center,

tel.: +38 (067) 548 8934,e-mail: [email protected]



PROVIDING COMPUTEREQUIPMENT TO KRYVYI RIHAIDS CENTER MONITORINGAND EVALUATIONDEPARTMENT SPECIALISTS

Success story categories by relevantClASS Modules: Administrative; Financial; HIVCounseling and Testing; and Clinical

Health care facility that made theimprovement: Kryvyi Rih AIDS Center


Effective work of a modern health care facilityis impossible without adequate technical andinformational support. When ClASS assessmenttook place, Kryvyi Rih AIDS Center had a limitednumber of computers: seven of 2005 models forthirty-five full-time employees with only one PCconnected to the Internet. Because of this, moretime was required to complete tasks by allfacility staff members, including newlyestablished Monitoring and EvaluationDepartment specialists. In addition, this situationaffected the quality of their work. In particular,with outdated computer equipment, it wasimpossible to compile the data and performcomprehensive HIV/AIDS analysis since it wasrestricted by capabilities of software «DevInfo»,«ArcGIS», and «SPECTRUM».

The results of ClASS assessment conductedin this facility in March 2015 defined this issueas one of the areas for improvement and drewattention of the management team to theunsatisfactory condition of technical andinformational support.


Implemented improvementinitiative

To implement the CIASS expertrecommendations according to the developedAction Plan, Kryvyi Rih AIDS Center Chief Doctorsent an official letter to the Ukrainian Center forDisease Control of the MOH of Ukrainerequesting assistance in the provision ofcomputer equipment for the M&E Departmentwithin this facility. The facility team used theCIASS report and approved Action Plan asadditional justification of the need to strengthentechnical and informational support.

Key results of the improvementinitiative

This request resulted in the update of thefacility computer equipment:

• With financial support from the project onM&E Technical Assistance and ImprovedData Application in HIV (METIDA), KryvyiRih AIDS Center received four desktopcomputers and a multifunctional device.

• In addition, Kryvyi Rih Unit of All-UkrainianNetwork of PLHIV provided a laptop fortemporary use by Kryvyi Rih AIDS Center.


Since the end of 2017, Kryvyi Rih AIDS CenterM&E Department specialists have had

continuous Internet access and their workstationshave been fully equipped with modern computerequipment. Electronic devices and modernsoftware help M&E Department specialists tofulfill their responsibilities effectively, analyze andforecast HIV epidemic development tendencies,and consolidate and verify HIV/AIDS medical andstatistical information promptly.

Therefore, implementation of CIASSrecommendations contributed to thestrengthening of informational and technicalcapacity of the facility.


ClASS assessment and implementation of therecommendations allowed the Kryvyi Rih AIDSCenter to receive the unique and practicalexperience of attracting and using new financialand technical support sources and to establishcooperation with non-governmental organi-zations and international technical assistanceprojects.

Statements and feedback ofrepresentatives of the health carefacility that made the improvement

Hennadiy Kruhlenko, Chief Doctor of KryvyiRih AIDS Center:

“…CIASS assessment is a very useful formof methodological support to health care facilities


Photo: M&E Department staff work on computersKryvyi Rih AIDS Center received during

CIASS recommendations implementation


that do not pay attention to some issues in theirroutine activities. Only independent expertsassessing a facility can identify existing issuesand most importantly provide professionalrecommendations on areas for improvement. Iwould like to wish the experts fruitful cooperationand improvement of professional level of facilitiesby means of CIASS assessment.”

Viktoria Dovhoruchenko, Head of Kryvyi RihAIDS Center M&E Department:

“Because of CIASS assessment we were ableto update computer equipment for the M&EDepartment. For us it was an achievement sincethe M&E Department staff are the ones usuallymost impacted by the lack of computerequipment, internet, and local computernetwork.”


Implementation of the assessmentrecommendations was made possible by theparticipation of the following organizations inthis process:

• Public Health Center of MOH of Ukraine

• Project on M&E Technical Assistanceand Improved Data Application in HIV(METIDA)

• Kryvyi Rih Unit of All-Ukrainian Networkof PLHIV

• All-Ukrainian Network of PLHIV


Viktoria Dovhoruchenko, Head of Kryvyi RihAIDS Center M&E Department,




LAUNCHING A NEW TRUSTROOM TO IMPROVE ACCESSTO HEALTH CARE SERVICESFOR HIV�POSITIVE PATIENTSIN POLTAVA OBLAST

Success story category by relevant ClASSModule: HIV Counseling and Testing; Clinical

Health care facility that made theimprovement: Poltava Oblast AIDS Center


Since its foundation in 2001, Poltava OblastAIDS Center Ambulatory and PolyclinicDepartment have been located in an adaptedhistoric building. The ClASS assessmentconducted in July 2016 found that, since thenumber of employees had increased, theavailable rooms and square meters did not meetthe current needs of the facility. In someinstances two Infectious Disease Doctors had tosee their patients in the same roomsimultaneously, which was against theconfidentiality and patient flow segregationrequirements and created unfavorable workingconditions for doctors.

ClASS experts provided the followingrecommendations:

• To separate the Administrative Departmentfrom the Ambulatory and Polyclinic one, forinstance, by relocating one of them toanother building;

• Ensure functioning of Poltava Oblast AIDSCenter Trust Room.



ClASS expert recommendations streamlinedlocal authority administrative decisions withregard to the expansion of the size of the TrustRoom. Considering sufficient staffing of theAmbulatory and Polyclinic Department, as wellas availability of an additional 90 square meterbuilding at the Poltava City Clinical Hospital No.4,Poltava Oblast AIDS Center renovated fourrooms within the hospital premises with thefinancial support provided by the Light of Hopecharitable organization. At the beginning of 2017an Infectious Disease Doctor, a Counselor, aNurse, and a Social Worker have been placedthere. Since then, such services to PLHIV as HIV,TB, and viral hepatitis diagnostics, HIV medicalmonitoring and treatment, ART laboratory andsocial and psychological support, as well asreferral of patients with opioid addiction to OSThave been provided at different addresses.


The availability of rooms and close cooperationwith primary health care workers ensuredfavorable conditions for the increase in patientnumbers. Conditions appropriate for ART drugsstorage and individual and group pretestconseling are established. All these ensuresaccess to HIV specific treatment at the places ofresidence as well as the patient statusconfidentiality.


ClASS assessment helped Poltava OblastAIDS Center:

• To combine facility resources and effortswith those of other organizations to equipand launch the Trust Room;

• To develop abilities of facility specialists toattract external technical support, namely,to enhance skills for project planning andnegotiation with potential partners anddonors.

Statements and feedbackof representatives of the healthcare facility that made theimprovement:

Oksana Danylenko, Poltava Oblast AIDSCenter Chief Doctor:

“CIASS expert recommendations wereimportant when convincing local authorities toprovide premises and Trust Room set up supportand expedited its launch at the City Hospital.”

Liudmyla Derevianko, Poltava Oblast AIDSCenter Trust Room Counselor:

“The improvement of working conditions at theTrust Room at Poltava City Clinical Hospital No.4resulted in an increase in the number of patientsseeking assistance. Expansion of the actualspace (separate areas for counseling, Infectious


Picture: Information about HIV/AIDS CounselingTrust Room at Poltava City Clinical Hospital

No. 4

24 Clinical Assessment for Systems Strengthening (ClASS)

Picture: 1) Patient counseling in the TrustRoom; 2) Providing medical servicesto a patient in the Trust Room.


Disease Doctor appointment, and laboratoryprocedures) and provision of equipment andfurniture helped us to create conditions requiredfor a comprehensive package of medicalservices, ensure more open communication,build trust, and receive feedback.”


The updated Trust Room was launchedunder direct supervision of Poltava OblastState Adminis-tration in cooperation withHealth Care Administration of Poltava CityExecutive Committee with financial supportfrom the Light of Hope charitable organizationand by the initiative of the facility staff.


Kateryna Mykhailova, Deputy Chief Doctoron Prevention, Organizational, andMethodological Activities and EpidemiologicalMonitoring of Poltava Oblast AIDS Center,




IMPROVEMENT OF ACCESSTO TREATMENT SERVICES(ART) FOR TB/HIVCO�INFECTION PATIENTSIN CHERKASY OBLAST

Success story category by relevant ClASSModule: Clinical

Health care facility that made theimprovement: Cherkasy Oblast AIDS Center


The ClASS assessment in Cherkasy OblastAIDS Center in June 2014 detected severalissues causing a rather low coverage of TB/HIVco-infection patients by ART in the oblast (51.1%in the 2013 cohort). Namely:

• Facility staffing plan included only 0.25 FTEfor TB specialist position, and even thatwas not filled. As a result, Cherkasy OblastAIDS Center could not provide integratedservice of prescription and administrationof TB prophylaxis directly in the facility.

• TB/HIV co-infection patient record systemand the analysis of TB incidence amongHIV-infected patients were usedineffectively.

Due to the absence of Infectious DiseaseDoctor within the In-patient Department ofCherkasy Oblast TB Dispensary, patients werenot prescribed ART in time. Using theassessment results, CIASS experts provided thefollowing recommendations to resolve theidentified issues:


• Ensure improved access to HIV treatmentservices for Cherkasy Oblast TB Dispen-sary patients by launching a Trust Roomwith the function of ART administration atthe facility;

• Introduce routine TB prophylaxis practiceinto Cherkasy Oblast AIDS Center;

• Fill the TB specialist position at CherkasyOblast AIDS Center.


Cherkasy Oblast State Administration HealthCare Department, Cherkasy Oblast TBDispensary, Oblast Council on TB and HIV/AIDS,Oblast Council on TB and HIV/AIDS Cross-Sectoral Work Group, and non-governmentalorganizations were involved in the imple-mentation of the provided recommendations.

The questions of ART site launch, fillingInfectious Disease Doctor position, and extendingresponsibilities of the TB specialist at CherkasyOblast TB Dispensary were considered by theCherkasy Oblast State Administration HealthCare Department and Oblast Council on TB andHIV/ AIDS. In addition, Cherkasy Oblast TBDispensary asked non-governmental organi-zations to provide assistance equippingInfectious Disease Doctor workstation.

Photo: Information on Cherkasy Oblast TBDispensary



Thanks to the active support of the OblastCouncil on TB and HIV/AIDS Cross-SectoralWork Group, a decision was made to introducea TB specialist position into Cherkasy OblastAIDS Center and attract donor funding to equipa TB Doctor room. Currently, TB prophylaxis forHIV-patients receiving medical services inCherkasy Oblast AIDS Center is prescribed andadministrated by this facility.

Moreover, in July 2015 an ART site waslaunched at Cherkasy Oblast TB Dispensary.ART for patients receiving TB/HIV co-infectiontreatment is prescribed and administered by thefacility.

Additionally, clear record kepping on TB/HIVco-infection patients in both facilities was ensuredusing electronic TB Patient Registry.


Implementation of ClASS recommendationswith regard to the ART site launch at CherkasyOblast TB Dispensary and provision of TBchemoprophylaxis at Cherkasy Oblast AIDSCenter helped to improve quality of health caremaking it possible for patients to receive servicesdirectly at the locations of their main treatment.The implementation of these recommendationsallowed for increase in ART coverage indicator

for the TB/HIV co-infection patients from 51.1%(2013) to 64% (2015). Based on the work resultsin the first quarter of 2017, ART coverageindicator for the first and third category of TB/HIV co-infection patients was 84.2%, while theindicator of ART prescription during first eightweeks upon TB treatment initiation increased to75% compared with 35.5% in the first quarter of2015.


• It was necessary to improve access to ARTfor TB/HIV co-infection patients inCherkasy Oblast even before the CIASSassessment. However, the assessmenthelped to identify the issue more clearly,improve understanding of its negativeeffect on the quality of health care servicesprovided, and develop steps to resolve it.

• While implementing the ClASSrecommendations, Cherkasy Oblast AIDSCenter gained experience of attractingassistance from the partners andestablishing effective cooperation withgovernmental and non-governmentalorganizations to resolve health careprovision issues in the oblast.


Photo: Infectious Disease Doctor Oleh Akulin is providingcounseling to TB/HIV coinfection patients at ART site at

Cherkasy Oblast TB Dispensary


Statements and feedbackof representatives of the healthcare facility that made theimprovement:

Liudmyla Komasko, Infectious Disease Doctorof Cherkasy Oblast AIDS Center:

“At the beginning we were rather skepticalabout CIASS assessment, thinking it was justanother inspection to identify our gaps andviolations. However, we changed our mind uponreceiving clear recommendations for potentialimprovements instead of the «revealing andaccusatory inspection certificate». Thanks toCIASS experts, we learned to see our problemsfrom different angles and started properly framingour needs.

Today we hope that upon ART site launch atthe TB Dispensary and filling the position of aTB specialist we will be able to resolve the issueof record kepping for TB/HIV patients andimprove the referral system, with other TB/HIVco-infection related problems hopefully becomingobsolete.”

Petro Levchenko, Chief Doctor of CherkasyOblast AIDS Center:

“We used CIASS expert recommendations toinfluence the Oblast Health Care Administrationdecisions. Thus, we were able to resolve organi-zational and staffing issues promptly. We laun-ched an ART site at the Oblast TB Dispensary,and now TB/HIV co-infection patients can receivetreatment “on site”. I believe it is great. I hope tohave many more chances to work with CIASSexperts.”


Information about partners involved in theimprovement initiative:

The implementation of the assessment recommendations waspossible because of the following organizations participation:

• Public Health Center of MOH of Ukraine;

• Cherkasy Oblast State Administration Health CareDepartment;

• Oblast Council on TB and HIV/AIDS and its work groups;

• Cherkasy Oblast TB Dispensary;

• Cherkasy Oblast Unit of All-Ukrainian Network of PLHIV;

• Cherkasy PLHIV charitable organization “From Heart toHeart”.

Contact person for more information regardingthis success story:

Iryna Bilous, Deputy Chief Doctor on Medical Services toPopulation of Cherkasy Oblast AIDS Center,




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Success story category by relevant ClASSModule: HIV Counseling and Testing

Health care facility that made theimprovement: Chernivtsi Oblast AIDS Center


During ClASS assessment in ChernivtsiOblast AIDS Center, HIV-positive patients werenot able to enter into medical care at the CentralRayon Hospital since ART was prescribed by theOblast AIDS Center only.

Partially due to this, the indicator of HIV-positive patients coverage was 61% of the totalnumber of HIV-positive people stated in theseroepidemiologic monitoring data of 2015. Inother words, about a third of all HIV-positivepeople with confirmed HIV infection in 2015 werenot monitored and, therefore, not receiving ART.

In addition, there was an issue of latedetection: 44.4% of newly diagnosed HIVpatients were diagnosed with HIV at III-IV clinicalstages (2015).

Recommendations based on the assessmentconducted by the CIASS experts at ChernivtsiOblast AIDS Center in 2015 included:

• Organize monitoring visits to oblast healthcare facilities with regard to the issues ofpre-test counseling and completing recordand reporting documentation;


Photo: Periodic trainings for Infectious Disease Doctors inChernivtsi Oblast on the issues of HIV counseling and

testing and maintaining record and reporting documentation


• Conduct HIV/AIDS trainings for InfectiousDisease Doctors.


To implement recommendations upon theconducted assessment, the acting Chief Doctorsent a letter to AbbVieBiopharmaceuticals GmbHasking to support financially periodic trainings onHIV counseling and testing and maintainingrecord and reporting documentation for healthcare specialists in Chernivtsi Oblast.


The funding request was met. Today,according to the Order approved by ChernivtsiOblast State Administration Health CareDepartment, Chernivtsi AIDS Center providesquarterly trainings on HIV counseling and testingand maintaining record and reportingdocumentation in the facility. By now, forty-eighthealth care specialists have received suchtrainings.


Based on the data provided by ChernivtsiOblast AIDS Center, the quality of records andreporting documentation completed by rayonlevel facilities and submitted to the Oblast AIDSCenter by trained specialists improvedsignificantly. In addition, results of the interviewsconducted among patients were indicative of thebetter quality pre-test counseling services.


Recommendations that the facility receivedduring CIASS assessment served:

• As a source of expert information to identifypriority direction for further improvement,planning and implementation;

• To find necessary resources and technicalassistance at the regional level.

Statements and feedbackof representatives of health carefacility that made the improvement

Volodymyr Mochulskyi, Chief Doctor ofChernivtsi Oblast AIDS Center:

“CIASS assessment is something new andinteresting! It has a great potential for further useby the Heads of health care facilities. Unliketraditional health care quality control approaches,


Photo: Periodic trainings for Infectious Disease Doctors inChernivtsi Oblast on HIV counseling and testing and

maintaining record and reporting documentation


CIASS is not an audit; it is rather an “advisor” infinding resources to ensure high quality servicesprovision. I am convinced that implementationof all recommendations will get our facility to anew, higher quality level of resource management.”

Serhiy Sorokatyi, Head of Chernivtsi OblastAIDS Center M&E Department:

“CIASS assessment showed me as a Headof M&E Department the strengths and areasrequiring improvement in our facility. Theassessment was friendly in nature and helpedus to see the gaps from a different angle; at thesame time, it was not an inspection. Assessmentreport was a good push in the preparation of ourfacility towards accreditation.”

Iryna Karaushu, Head of Ambulatory andPolyclinic Department of Chernivtsi Oblast AIDSCenter:

“CIASS assessment provided me withprofessional recommendations and was notdesigned as an audit. For me, the assessmentreport is a source of objective information thatcan serve the needs of planning and taking futuresteps for the improvement of facility managementand PLHIV treatment quality in ChernivtsiOblast.”


The following organizations participated inthe initiative implementation:

• Chernivtsi Oblast State AdministrationHealth Care Department;

• AbbVieBiopharmaceuticals GmbH.

Information about periodic trainings waspublished on Chernivtsi Oblast AIDS Centerweb site (www.snid.cv.ua) and Facebookpage.


Volodymyr Mochulskyi, Chief Doctorof Chernivtsi Oblast AIDS Center,




DECENTRALIZATIONOF HIV SERVICESIN CHERNIHIV OBLAST

Success story category by relevant ClASSModule: Clinical

Health care facility that made theimprovement: Chernihiv Oblast AIDS Center


During ClASS assessment at Chernihiv OblastAIDS Center in August 2016, in the oblast therewere three Trust Rooms with ART prescriptionfunction, namely, at Pryluky Central City Hospitaland Kozelets and Novhorod-Siverskyi CentralRayon Hospitals.

As of August 1, 2016, the portion of PLHIV inChernihiv Oblast receiving ART at these threefacilities was only 6% (109 people) of the totalnumber of PLHIV on ART in the region. At thesame time, the share of people on treatment atChernihiv Oblast AIDS Center was 94% (1698people). Significant negative consequences oflow coverage by HIV services (ART) includedlimited access to examination and non-timelyART prescription for patients from remote oblastareas; patients having to spend time and moneyto get to Chernihiv; and Chernihiv Oblast AIDSCenter Infectious Disease Doctor high workload.


Taking into account the above-mentionedissues, CIASS experts provided the followingrecommendations:

• Ensure further decentralization of bothmedical monitoring and follow-up ofpatients on ART to Trust Rooms orInfectious Disease Doctors close to theplaces of residence;

• Ensure patients preparation to ARTinitiation and/or their referral to Oblast AIDSCenter for ART prescription (if no ART siteavailable).

Improvement InitiativeTo implement the assessment recommen-

dations, and, in particular, officially launch thesites and ensure their effective functioning andsites specialists’ training, Chernihiv Oblast AIDSCenter involved a number of stakeholders:Chernihiv Oblast State Administration HealthCare Department; HIV/AIDS Oblast CoordinationCouncil (further on – Coordination Council);Chernihiv Oblast Unit of All-Ukrainian PLHIVNetwork; and the “Renaissance of the Nation”non-governmental organization.


The issues of Trust Rooms functions expan-sion and treatment services decentralizationwere discussed at medical meetings andCoordination Council sessions. This resulted inthe approval of Chernihiv Oblast StateAdministration Health Care Department Order ofDecember 16, 2016, No.394 “On theDecentralization of ART Provision in the Oblast”,upon which, as of the beginning of 2017, threenew sites prescribing and monitoring ART werelaunched in the oblast: at Nizhyn Central CityHospital and Koriukivsk and Mensk CentralRayon Hospitals.

Thanks to support from Chernihiv Oblast Unitof All-Ukrainian PLHIV Network and local andrayon councils, new ART site facilities were setup for operation. In addition, oblast participationin a pilot testing of HIV MIS (HIV MedicalInformation System) helped to equip oblast TrustRooms with modern computers.

The Trust Rooms specialists receivedtrainings on ART access and service qualityimprovement in the oblast and up-to-date clinicalrecommen-dations on ART. They participate inpractical trainings at Chernihiv Oblast AIDSCenter on a regular basis.


Photo: Infectious Disease Doctor OleksandrBulitko during patient counseling at the Koriukivsk

Central City Hospital Trust Room



Implementation of CIASS recommendationshelped to improve access to care for HIV patientsand make it closer to their places of residence.For instance, all six Trust Rooms in the oblastcollect blood samples for CD4 testing, and, whereapplicable, HIV viral load testing and transportthem to Chernihiv Oblast AIDS Center HIVDiagnostic Laboratory.

Based on the results of the first half of 2017,the portion of patients receiving ART at TrustRooms in rayons of Chernihiv oblast was 8.1%.

Unique experience gainedby the health care facility

CIASS assessment helped Chernihiv OblastAIDS Center to:

• Receive expert opinion to identify the issueand understand its importance;

• Combine its resources and efforts withthose of other organizations to resolve theissue.

Statements and feedback ofrepresentatives of health carefacility that made the improvement

Halyna Lysenko, Acting Chief Doctor ofChernihiv Oblast AIDS Center:

“CIASS assessment in Chernihiv Oblast wasvery timely. Unlike monitoring visits, we did notreceive directives for implementation, butidentified our strengths and recommended areasfor improvement. CIASS assessment wasconducted in the form of an interview withspecialists on a patient pathway, which changedthe perception and shifted the focus from controlfunctions and audit to professional recommen-dations. This technique is useful while preparingfor facility accreditation.”

Olha Tereshchenko, Infectious DiseaseDoctor of Chernihiv Oblast AIDS Center:

“The decentralization process was activatedin the oblast as a result of the CIASS assessment:the provided recommendations had beenrelevant for a long time, yet an outsideperspective helped to streamline this process.Patients in our oblast received an opportunity forexamination and ART without leaving theirrayons, since the most remote from the OblastAIDS Center areas are 200 km away. We hopethat new ART sites launch will not only improveaccess to treatment and the whole system of HIV-infected patients care, but also contribute tostigma reduction.”


Information about partners involved in theimprovement initiative:

The following organizations participated in the initiativeimplementation:

• Public Health Center of MOH of Ukraine;

• Chernihiv Oblast State Administration Health CareDepartment;

• Chernihiv Oblast HIV/AIDS Coordination Council;

• All-Ukrainian PLHIV Network;

• Chernihiv Oblast Unit of All-Ukrainian PLHIV Network;

• “Renaissance of the Nation” non-governmental organization.

Contact person for more information regardingthis success story:

Olha Maliuta, Head of Ambulatory and Polyclinic Department ofChernihiv AIDS Center,

tel.: +38 (098) 036 9395,e-mail: [email protected],website: www.spidcentr.com.ua


All presented success stories demonstrate that the issues (areas for improvement)existed even before the CIASS assessment. However, thanks to the expert opinionand clear objective recommendations, health care facilities participating in theassessment approached solutions to their issues as initiatives they can implement.

In addition, these stories prove the importance of health care facilities activeparticipation in finding the resources and support they need, in particular, throughassistance from oblast or local executive authorities and cooperation with non-governmental organizations, businesses, and donor agencies.

Presented examples differ in the scope of achieved improvements and are uniquefor each organization. However, they are similar in the sense that CIASSrecommendations implementation has helped the facilities to develop their capacitiesand gain experience of change initiation to improve the quality of health care servicesfor PLHIV in Ukraine.

CONCLUSIONS

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