Quality improvement is distinct from and complements monitoring and evaluation. Structured quality improvement means reflecting on all phases and aspects of a project or intervention in order to identify areas for improvement. Monitoring and evaluation data and results can inform quality improvement.
Quality improvement formally identifies, implements and evaluates strategies to maximise the potential of an activity, including increasing its capacity to fulfil and exceed quality standards. It can be used at any stage of an activity and always aims for improvement, no matter what the starting point is.
It may include quality assurance, which formally monitors the quality of services and activities against standards (where they exist), including review, problem identification and corrective action. Quality assurance processes are particularly suitable for standardised and routine components, such as medical and clinical procedures.
Effectiveness can be maximised through a specific focus not just on ‘doing the right things’, but on ‘doing the right things right’. It aims to ensure that decisions about what to do and which methods to use are based on the best available evidence, knowledge and experience, and that the chosen activities are planned, implemented, monitored and evaluated to maximise their potential affect.
Quality improvement highlights what you are doing well already, boosting motivation and morale. It encourages teams to reflect on the CBVCT as a whole and uses the participation of further stakeholders to identify areas of improvement and innovation and break them down into concrete, practical steps.
Using structured quality improvement tools in a safe environment that enables self-reflection, and with the participation of all relevant stakeholders to increase the diversity of perspectives, can yield unexpected insights and innovative, creative improvements.
Here are some key questions to start with structured quality improvement:
- Are there quality criteria or standards available for the work?
- Are there good practice examples?
- Do we need a tool to help us reflect on our work?
- Do we need technical assistance to introduce quality improvement practices?
Structured quality improvement tools in the form of questionnaires and facilitation guides, including a tool selection guide and online learning resources are available on www.qualityaction.eu. It is best to start small, e.g. use a section of one of the tools in a team meeting, creating a space for self-reflection without fear of blame or humiliation where all perspectives and ideas are respected. If people have a positive experience of quality improvement and experience the benefits for their own work, they are more likely to want to engage with it more fully and use the whole tool next time.
You can also find a searchable database of case studies written by teams who have done this, including CBVCTs, on www.qualityaction.eu. A European network of trainers and facilitators who are experienced in quality improvement and using the tools can provide technical assistance and advice to make it easier to engage with quality improvement.
Innovation and expansion
Question thirteen of the Euro HIV EDAT Self-evaluation Grids focuses specifically on developing additional capacities and integrating new prevention tools.
Structured quality improvement activities – or any reflective practices – result not only in practical steps to improve operations, but often identify barriers that are beyond the CBVCTs immediate control and therefore become advocacy issues (see the section on advocacy).
If a range of perspectives are included, they are also likely to discover unmet needs and gaps in service provision that the CBVCT could fill by expanding its own scope beyond the core services of HIV testing and counselling, information and referral.
CBVCTs may consider expanding activities in the areas of:
- Coverage (e.g. by adding outreach services or targeting new subpopulations)
- Accessibility (e.g. by changing or extending opening hours)
- Additional tests (e.g. by offering comprehensive STI testing)
- Harm reduction/prevention work for chemsex users (discussion groups, recovery drop-in groups, individual counselling, referral, needle exchange)
- Additional medical services (e.g. by providing an MSM-friendly general medical service)
- Additional psychosocial services (e.g. by offering counselling, group work, mentoring etc.)
- Networks (e.g. by linking with GLBTIQ* community initiatives)
Pre-exposure Prophylaxis (PrEP)
PrEP, the regular or intermittent use of antiretroviral drugs by HIV negative people to prevent HIV acquisition, is becoming a building block of HIV prevention, especially for key populations at high risk of HIV infection. Already, France is providing PrEP for all who need it.
Discussions about whether, how and where to provide PrEP are under way in many other European countries, and there are strong arguments why CBVCTs, as community-based services for MSM, are well-placed to play a central role in providing access to PrEP. The Barcelona Checkpoint has articulated these reasons:
Why a community centre for the delivery of PrEP?
- Persons who are HIV negative are not used to going to hospitals
- Easy to talk to peers about sexuality, (not) using condoms, risk perception and risk reduction
- 10 years of experience with HIV rapid testing and linkage to care
- Promoting regular testing for people at highest risk (4 times/year)
- New technologies and fast results for viral load testing
- STI screening (Syphilis, NG, CT, HCV) already implemented
- Long-term collaboration with HIV clinics and physicians
- Experience with patient preparedness for treatment and adherence issues
- Community outreach, awareness and information on PrEP.
(Source: bcn Checkpoint)
Self-sampling and Self-Testing
Self-Sampling and Self-Testing are available in more and more European countries. In some countries they are a crucial part for higher testing rates among MSM. Please read the recommendations by Workpackage 9.1 from Euro HIV EDAT for more information.
The recommendations can be found here: Recommendations on self-testing and self-sampling
Swab2know by Euro HIV EDAT was a pilot intervention to assess the acceptability and feasibility of an outreach intervention for HIV tetsing among MSM and migrants and Online Communication of Test Results was implemented in 6 European countries (Belgium, Spain, Portugal, Denmark, Rumania and Slovenia). Two websites to delivery test results and post test couselling were developed (www.swab2know.eu and www.lapruebaencasa.com). They were translated to the languages of the participating countries. An implementation manual for an integrated strategy for HIV testing using CBVCT, outreach and web based techniques was developed. It is available at: Swab2know: Manual for the development and implementation of an HIV testing approach using outreach and home sampling strategies and online communication of HIV test results.
Any innovative expansion of the CBVCTs scope of operations may require additional resources, which in turn may depend on making a good case for additional funding, supported by local evidence.
Documenting participatory processes well and using data from monitoring and evaluation activities can yield practice-based and corroborating evidence. This can help make general epidemiological or social research evidence on the holistic health needs of MSM locally relevant.