PEPFAR Care that Counts Initiative :: Programming ::

Orphans and other children affected by HIV/AIDS receive psychosocial support, India. © 2004 Gideon Mendel for IHAA.

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PEPFAR Care that Counts Initiative

In response to the growing number of children affected by HIV/AIDS, efforts to provide services, including basic shelter and care, education, health care, nutrition, legal protection and psychosocial support have sprung up throughout Africa. As these programmes mature and expand, implementers and donors are asking about the impact and quality of the care they are providing. What is quality care? And what makes a difference for children? This section of the website hosts the Quality Improvement Initiative for OVC Programmes, a new partnership of USAID and OVC implementing partners to improve quality of care for children affected by HIV/AIDS. Quality care is the degree to which services maximise benefits and minimise risks, so that children may grow and develop. This definition implies a focus on outcomes of child health and well-being, rather than simply a count of services provided or received. In 2006, several countries and programmes began exploring how quality could be defined, assessed and improved. While some commonly asked questions challenged the focus on quality because of the dire need for expanded coverage with OVC services, it is essential to focus on access and quality in order to make a meaningful and positive difference for children and to have programmes that are effective, efficient and equitable. Key building blocks to date have been the dimensions of quality , the underlying basic foundations of the standards, and a series of illustrative composite standards for OVC care that are based on country experiences and best practices to date.

QI core principles

QI builds on the concept that 'performance is a characteristic of care provision' and that improvement will occur only when changes are made in the system. Adding inputs to a system will only lead to improvement to the extent they can effect change in that system. QI is based on four core principles:

  1. Being client centered: keeping in mind that the needs of the children being served are at the core of what we do (see Listening to the voices of children).
  2. Multi-disciplinary team approach: bringing together the range of individuals who make up the team responsible for service delivery efforts to children.
  3. Focus on how care is actually provided: examining and modifying the systems and processes used to provide care.
  4. Data-based decision making: using data to determine where we are, what are the gaps, what we want to do, whether what we did made a difference?

The quality triangle available in this document illustrates how articulating desired outcomes, defining quality, measuring quality and improving quality all work together in a continuous process to make a measurable difference to the children being served by our OVC programmes.

Defining Desired Outcomes

Desired outcomes tell us how we hope to make a difference for children in measurable terms. For example, children are in school and performing at grade level. OVC stakeholders agree on desired outcomes for each service area as a first step in quality improvement.

What do we mean by “outcomes”? Outcomes are measures of knowledge, attitudes, values, skills, behavior, condition, or status. These measures should reflect changes that occur when needed services are provided. In OVC programming, there is usually more than one outcome, and these outcomes are often connected and inter-related.

Defining desired outcomes is a critical step in defining quality and service standards. Once the outcomes are clear, it is much easier to define actions that are likely to achieve the desired result. Each country will want to decide on desired outcomes appropriate to their local context.

To be useful for improving quality, outcomes must be measurable. Being able to measure outcomes allows programs to examine whether strategies, processes of care, and service delivery model programs are effectively reaching the children and making a significant difference for them. However, not all outcomes are easily measured, and implementers are encouraged to think of proxy indicators to assess how their programs affect children’s lives.

Defining quality

“Defining quality” means articulating the characteristics or parameters of services that will lead to the desired outcomes. Quality care for vulnerable children can be defined as the degree to which the services provided to children, families and communities maximise benefits and minimise risks, so that children may grow and develop. Quality care implies that the correct mix of services is offered based on current best practices and indigenous and expert knowledge. Defining quality requires a client-centered approach to ensure services are relevant to needs and context.

A step-by-step process for establishing service standards has been developed and tested in three countries (Ethiopia, Namibia, and Zimbabwe) and is currently being used by many others. This process uses a number of key inputs:

  • Existing evidence, best practices and existing related standards
  • Youth input: information from clients themselves on what is important to them
  • Articulation of the dimensions of quality

These inputs are then used to identify essential actions and guidelines that comprise the service standards. The result of this process is OVC stakeholder consensus on essential minimum actions that constitute each service area. Agreement on standards will increase consistency, especially when reporting on number of children served.

Quality has many dimensions including safety, access, effectiveness, technical performance, efficiency, continuity, compassionate relations, appropriateness, participation and sustainability. The dimensions of quality can provide a powerful lens to look at how well care is being provided now and how activities can be implemented with increased quality.

Once quality standards are defined, moving standards to the field and operationalising them is the next challenge. Read how countries are dealing with these challenges in Latest from the field.

Measuring quality

The key objective of quality improvement is closing the gap between existing and desired levels of quality. In order to evaluate quality and verify progress, measurement is necessary. Quality measures can include an assessment of the extent to which standards are currently being met, client and volunteer satisfaction, and whether desired results are being achieved. Tracking changes takes place throughout quality improvement efforts.

Measuring quality involves developing routine collection and analysis of data through supervisory assessments, volunteer and staff self-assessments or periodic studies. Both quantitative and qualitative information can be used to reflect on progress. It is vital to gather information that is meaningful and useful to service providers. Monitoring should focus on both process and outcomes, especially when outcomes may be related to multiple factors and may not manifest themselves in the short term. Many in the OVC community are tackling the challenge of developing systems for monitoring quality and process.

The Child Status Index (CSI) is a tool available for OVC programmes interested in comprehensively tracking the status of child well-being. It provides a series of benchmark outcomes in six key domains. Communities and local governments can use the CSI to determine whether the totality of care and support, beyond direct service provision, is having a positive impact on vulnerable children. The CSI is being extensively piloted and updates will be provided on this website.

Measuring quality works best as an interactive process. All service providers, volunteers, staff and management should participate in tracking their programmes' effectiveness. Children, families and communities also play an essential role in the process of measuring quality, as they can articulate whether the programme is meeting their needs.

Improving Quality

Improving quality includes all efforts to do a better job of achieving the desired outcome for children, and at the same time enhance the efficiency and reach of services and programmes. In the past, efforts to improve quality often focused almost exclusively on developing standards and providing training; however, recent experience shows the power of other strategies, such as supportive supervision, team-based process improvement, and improvement collaboratives and communities of practice.

"Every system is perfectly designed to get the results it is achieving” (Paul Batalden). In other words, if you want to improve quality, you need to change something that you are doing. However, not all changes are an improvement. Determining what to do to make improvements becomes an important step in the process. 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 often strengthen the learning process and result in best practices.

Quality improvement also leverages supervision skills to support teams in the process of improving quality. For example, supervisors can use the dimensions of quality to help teams reflect on current activities and application of service standards to reach outcomes. One dimension of quality - access, can encourage teams to consider ways to increase the number of vulnerable children who are able to receive services.

Several options to share learning from quality improvement experiences are being created, including this website. As programmes enter the stage of applying service standards in OVC programmes, more evidence and lessons learned will be posted. See How to get involved for more ways to engage in the Quality Initiative.

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