Figures & Tables
Figures
- Figure 1.
The 4 Steps of the Standards-Based Management and Recognition (SBM-R) Approach
- Figure 2.
Provider Performance: Percentage of Verification Criteria Achieved
n = 175 at baseline; 179 at endline.
*P<.001
Tables
ART Readiness Standards No. of Verification Criteria General Readiness Standards No. of Verification Criteria ART drug requisition: system for reordering drugs is properly managed 5 Staffing: sufficient staff are available for daily operations 3 ART drug storage: drugs are properly stored, tracked, and issued 9 Infrastructure: staff and client comfort and safety are assured 6 Pharmacist counseling: information on ART drugs is offered to clients 9 Supplies: sufficient stocks of critical supplies are available 3 Individual monitoring plan: plan is developed with client to monitor adherence and toxicities 8 Management systems: referral, scheduling, communication, and evaluation systems are working 7 Checking adherence: follow-up visits reinforce adherence to treatment, answer questions, and dispense drugs 11 Waste disposal: waste is handled and disposed of properly 5 Access to lab tests: clients' access to required laboratory tests is ensured 2 Client records: client files are kept confidential and are readily available 5 Blood drawing: infection prevention and other guidelines are followed 9 Health information system: timely collection, analysis, and reporting 5 Transport of blood samples: proper collection and transport to laboratory 3 Performance improvement: ongoing implementation of performance improvement activities 5 Maximum possible ART facility readiness score 56 Maximum possible general facility readiness score 39 Abbreviation: ART, antiretroviral therapy.
- Table 2. Performance Standards for Provision of ART Services, Standards-Based Management and Recognition
Standard No. of Verification Criteria Content Initial assessment of patient's condition 6 Greetings, registration, ask about patient well-being, review medical history Assessment of opportunistic infections 3 Rule out pneumocystis pneumonia, cryptococcal meningitis, and tuberculosis Assessment of adverse reactions 6 Inquire about sleeping problems, nausea, yellow eyes, shortness of breath, etc., and offer reassurance Assessment of potential drug interactions 3 Ask about new medications, document concurrent medications, check for drug interactions General health assessment 3 Inquire about contraception, pregnancy, alcohol and recreational drug use, depression; perform targeted physical exam; request and review laboratory tests Verification of how patient is taking ART and cotrimoxazole 9 Check medication schedule, supplies, missed doses; reinforce adherence; address patient concerns Addressing identified issues, as needed 8 Manage infections, adverse reactions, laboratory abnormalities; make referrals for social services Concluding the consultation 5 Address patient questions, plan return visit, complete registers and applicable forms Nutrition counseling 5 Discuss diet, food preparation, boiling drinking water, hand washing Maximum possible ART follow-up score 48 Abbreviation: ART, antiretroviral therapy.
- Table 3. Percentage Distribution of ART Client Characteristics in Zambia Defence Force Facilities, by Round of Data Collection and Study Group
Baseline Endline Characteristics Comparison Group
(n = 94)Intervention Group
(n = 81)P value Comparison Group
(n = 98)Intervention Group
(n = 81)P value Sex Male 60.9 50.6 .18a 32.7 53.1 .006a Female 39.1 49.4 67.4 46.9 Age, in years Mean (SD) 37.3 (8.3) 33.0 (9.4) .001b 34.3 (11.9) 35.8 (10.8) .39b Educational attainment Some primary 12.1 6.3 .14a 19.0 17.3 .01a Primary or 52.8 45.0 57.9 39.5 some secondary Secondary 35.2 48.8 23.2 43.2 or higher education Pregnant(among women only) Yes 10.8 10.8 .99a 7.9 8.3 .94a No 89.2 89.2 92.1 91.7 First or later ART follow-up visit First 8.8 1.2 .03a 7.0 10.0 .78a Second 3.3 8.6 10.5 10.0 Third or more 87.9 90.1 82.6 80.0 Duration of ART ≤1 year 42.7 38.5 .85a 36.6 33.8 .63a 2 years 40.7 43.6 28.0 23.8 3+ years 16.5 18.0 35.5 42.5 - Table 4. Facility Readiness to Offer Good-Quality Services: Percentage of Verification Criteria Achieved, by Data Collection Round and Study Group, Among Zambia Defence Force Health Facilities
Readiness Standardsa (No. of Criteria) Comparison Group (n = 4) Intervention Group (n = 4) Baseline Endline Change (% points) Baseline Endline Change (% points) ART facility readiness ART drug requisition (5) 100.0 100.0 0 100.0 100.0 0 ART drug storage (9) 92.6 85.2 −7.4 85.2 91.7 +6.5 Pharmacist counseling (8) 85.1 63.2 −19.9 92.6 75.0 −17.6 Individual monitoring plans (8) 81.3 65.2 −16.1 75.0 78.1 +3.1 Checking adherence (12) 63.2 73.2 +10.0 51.5 76.7 +25.2 Access to lab tests (2) 75.0 66.7 −8.3 100.0 100.0 0 Blood drawing (9) 96.4 77.8 −18.6 100.0 94.4 −5.6 Transport of blood samples (3) 50.0 50.0 0 62.5 87.5 +25.0 Total ART readiness score (56) 83.7 78.2 −5.5 88.5 86.2 −2.3 General facility readiness Staffing (3) 91.7 100.0 +8.3 100.0 91.7 −8.3 Infrastructure (6) 75.0 79.2 +4.2 86.7 95.8 +9.1 Supplies (3) 83.3 88.9 +5.6 100.0 100.0 0 Management systems (7) 100.0 96.4 −3.6 95.8 100.0 +4.2 Waste disposal (5) 80.0 73.8 −6.2 95.0 90.0 +5.0 Client records (5) 95.0 100.0 +5.0 95.0 85.0 −10.0 Health information system (5) 95.0 80.0 −15.0 95.0 100.0 +5.0 Performance improvement (5) 80.0 85.0 +5.0 90.0 100.0 +10.0 Total general readiness score (39) 85.8 93.9 +8.1 92.5 95.1 +3.4 Abbreviation: ART, antiretroviral therapy.
The number of criteria observed at each of the 4 facilities was summed for each readiness standard. This sum was calculated as a percentage of the total number of criteria for each standard, multiplied by 4 to include all 4 facilities.
↵a Missing values removed from numerator and denominator. N/A values recoded as missing.
- Table 5. ART Performance: Results of Bivariate and Multivariate Analyses of Percentage of ART Verification Criteria Achieved, by Data Collection Round and Study Condition, Among Zambia Defence Force Health Facilities
Bivariate Analysis ART Performance Standard and Study Condition % Achieved Change From Baseline to Endline Within Group Multivariate Analysisa Baseline
(n = 175)Endline
(n = 179)% Points P value Adjusted P value for Change Within Group P value for Interaction Initial assessment of patient's condition Comparison 90.1 92.3 +2.2 .08 .67 .001 Intervention 79.6 99.1 +19.5 .001 .001 Check for signs of opportunistic infections Comparison 86.2 67.8 −18.4 .001 .28 .13 Intervention 65.2 82.9 +17.7 .001 .33 Assessment of adverse reactions Comparison 61.2 50.0 −11.2 .005 .001 .10 Intervention 44.0 78.9 +34.9 .001 .22 Assessment of potential drug interactions Comparison 44.2 79.8 +35.6 .001 .001 .26 Intervention 33.1 80.7 +47.6 .001 .001 General health assessment Comparison 68.3 83.5 +15.2 .001 .25 .29 Intervention 62.3 93.0 +30.7 .001 .001 Verify how patient is taking ART Comparison 57.0 84.6 +27.6 .001 .05 .93 Intervention 59.8 91.0 +31.2 .001 .02 Addressing identified issues Comparison 32.9 60.1 +27.2 .001 .20 .93 Intervention 45.0 85.4 +40.4 .001 .001 Concluding the consultation Comparison 100.0 98.7 −1.3 .06 .17 .83 Intervention 100.0 98.1 −1.9 .03 .25 Nutrition counseling Comparison 4.6 2.0 −2.6 .09 .41 .001 Intervention 1.6 42.3 +40.7 .001 .001 Overall ART score Comparison 62.2 69.6 +7.4 .001 .13 .09 Intervention 57.5 84.2 +26.7 .001 .008 Abbreviation: ART, antiretroviral therapy.
P values ≤ .05 were considered statistically significant.
↵a Results from generalized linear regression with Poisson distribution adjusted for Zambia Defence Force branch and clustering within a facility.
GHSP-D-13-00053 Supplementary Material
The Zambia Defence Force has applied the Standards-Based Management and Recognition (SBM-R) approach at some of their military health facilities to improve antiretroviral therapy (ART) services. A study evaluating the effectiveness of the SBM-R approach examined 2 components of quality of care: (1) facilities' readiness to offer ART services, and (2) providers' performance during ART follow-up consultations. Readers are free to use or adapt the data collection tools below used in the study to evaluate these 2 quality components in their own programs and studies.
Files in this Data Supplement:
- Supplementary Material - Kim, et al. doi: 10.9745/GHSP-D-13-00053 Observation Checklist: Antiretroviral Treatment (ART) Follow up
- Supplementary Material - Kim, et al. doi: 10.9745/GHSP-D-13-00053 Performance Standards for Providing Antiretroviral Treatment (ART) in Zambia: Preparedness/Support Systems
In this issue
Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach
