The document outlines the National HIV Integrated Training Curriculum (NHITC), focusing on triage processes in healthcare settings and the management of patients with HIV. It emphasizes the importance of quick patient assessment, identification of those needing urgent care, and the creation of multidisciplinary teams for effective clinic management. Additionally, it discusses chronic care models, quality improvement cycles, and specific indicators for measuring performance in HIV services.

1. DELIVERY OF
CARE
NATIONAL HIV INTEGRATED
TRAINING CURRICULUM (NHITC)

2. Triage
Definition

3. Triage
3 principles of triage include:
i. Prompt assessment of patients on arrival
ii. Assessment by a qualified HCW who can rapidly classify patients based
on severity of illness or likelihood of deteriorating rapidly
iii. Patients identified as requiring urgent medical attention are seen by a
senior HCW immediately before other patients are attended

4. Process of Triage- Activity
•At the outpatient department in your health
facility, at the triage station, what equipment
and wall charts are available? What would
you recommend to facility management on
improvement of the triage station?

5. Importance of Triage
•Quickly identified and immediately stabilize the
critically ill.
•Facilitates infection prevention
•Can enhance task shifting by identifying stable
patients who can be seen by less experienced
•Can identify patients who need attention at
specific departments

6. Process of Triage
•Triage requires 3 steps:
i. Identifying patients who need to be seen
urgently
ii. Documenting the triage findings
iii. Providing urgent medical management for the
priority patient

7. Emergency Signs in Triage of Adults
• Patient unable to walk (if a change from baseline)
• Confusion, agitation, impaired consciousness, or convulsions
• Shortness of Breath at rest, patient unable to talk in complete
sentences because of shortness of breath
• Cyanosis (blue lips, tongue), choking
• Recent loss of body function (focal weakness or paralysis)
• Stiff neck

8. Emergency Vital Signs for Adults
• Temperature >40 °C or <35 °C
• Systolic blood pressure < 90 mm Hg
• Diastolic blood pressure ≥ 110 mm Hg
• Respiratory rate >30 breaths/minute
• Oxygen saturation of < 90% (if pulse oximetry is available)
• Vital signs are essential and they MUST always be taken

9. Priority signs for children
• Tiny baby: any sick child aged
under 2 months
• Temperature: child is very hot
• Trauma or other urgent surgical
condition
• Pallor (severe)
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, continuously irritable, or
lethargic
• Referral (urgent)
• Malnutrition: visible severe
wasting
• Oedema of both feet
• Burns (major)
3TPR MOB

10. Emergency Signs in Triage of Children
• obstructed breathing
• severe respiratory distress
• central cyanosis
• signs of shock (cold hands; capillary refill longer than 3 seconds;
weak, fast pulse)
• coma
• convulsions
• signs of severe dehydration in a child with diarrhoea (any two of:
lethargy, sunken eyes, very slow return after pinching the skin)

11. ESSENTIAL PACKAGE FOR PLHIV
• Knowledge of HIV status is the entry point into HIV care
• Core interventions
• to promote health
• improve the quality of life
• prevent further HIV transmission
• delay HIV disease progression and prevent mortality

12. ESSENTIAL PACKAGE FOR PLHIV- Activity
• Pamela is a 22 year-old female. She has been referred to an HIV
clinic in Lang’ata from Rongai VCT where she was newly
diagnosed with HIV. She is married with one child, a 3 year-old
son. Her baseline investigations have been ordered.
i. What services should be offered as routine care for Pamela?

13. MANAGEMENT OF A HIV CLINIC
•WHO summarizes the role of management as:
• Planning
• Implementation
• Evaluation

14. MANAGEMENT OF A HIV CLINIC
•12 C’s of a good team:
i. Clear expectations
ii. Context
iii. Commitment
iv. Competence
v. Charter
vi. Control
vii.Collaboration
viii.Communication
ix. Creative Innovation
x. Consequences
xi. Coordination
xii.Cultural change

15. MANAGEMENT OF A HIV CLINIC
• Vision, Mission and Objectives
• Vision - describe a set of ideals and priorities
• Mission - gives the how to the vision, lends a sense of
purpose to the vision
• Objectives - the specific things that must be done in order to
fulfil mission and achieve vision
• S- pecific
• M-easurable
• A-ttainable or Achievable
• R-ealistic
• T-imely or Time bound

16. Multidisciplinary Team
•What is a multidisciplinary team?
•Who should be present?
•What parts should they play?

17. Multidisciplinary Team
• Teamwork
• Sharing of ideas
• Professional support
• Ownership of patient and clinic activities
• Task sharing
• Emotional/psychosocial support
• Improved intra staff relationships

18. CHRONIC CARE MODEL
•The model elements include:
• Health Systems organization of Healthcare
• Clinical information systems
• Decision support
• Delivery system design
• Self-management support
• Community and organizational leadership

19. CHRONIC CARE MODEL

20. CHRONIC CARE MODEL
• The principles of good chronic care include:
• developing a treatment partnership with your patient, focus
on your patients concerns and priorities,
• Use the 5 A’s—Assess, Advise, Agree, Assist, Arrange.
• Support patient education and self-management.
• Organize proactive follow-up.
• Involve "expert patients", peer educators and support staff in
your health facility

21. CHRONIC CARE MODEL
•The principles of good chronic care include:
• Link the patient to community-based resources and
support.
• Use written information—registers, Treatment Plan,
patient calendars, treatment cards—to document,
monitor, and remind.
• Work as a clinical team (and hold team meetings).
• Assure continuity of care.

22. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
5 steps of the improvement cycle:
i. Setting priorities to identify specific areas/services for improvement
ii. Defining a performance measurement method for the improvement project and
use of existing data, or collecting data, that will be used to monitor successes
iii. Establishing an improvement team
iv. Understanding the processes of the underlying system of care so that
improvements can be implemented to effectively address problems
v. Making changes to improve care, and continually measuring whether these
changes actually produce the desired improvements in service delivery

23. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY- Activity
You realize that out of the 200 patients scheduled for appointment
last week only 90 patients (45%) visited the clinic as per the
appointment day. This gives your team at the clinic a difficult time
in identifying their files which could have been pulled out the
previous day.
i. State the problem in this scenario
ii. How would you use the PDSA cycle to help you and your team
to improve the gap(s) identified?

24. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
Model for Improvement

25. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
•The main reasons for carrying out a test are;
• To increase your confidence that the change will result in
improvement in your workplace
• So that you learn to adapt the change to conditions in the
local environment
• To help you minimize resistance when you move to
implementation

26. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY- Activity
Upon review of the routine reports generated from your clinic you may note that in
the last quarterly report there were a very small proportion of patients on second-
line treatment. The national HIV program indicates that at least 5% of all patients on
ART are likely to be on second-line ART. Your clinic report from the last quarter
indicates that only 1% of all patients on ART are currently on a second line regimen.
Together with the MDT, you decide to investigate this indicator further to find out if
you are missing patients or not evaluating properly who have failed their first-line
antiretroviral treatment and need to be switched to a second-line antiretroviral
regimen.
How will you do this?

27. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
Team Responsibilities
i. Reviewing results
ii. Understanding the process you are trying to improve: use simple tools such as
flow charts
iii. Working with facility leaders to set aims for improvement
iv. Developing ideas for testing changes that you believe will result in improvement
v. Routinely measuring and reviewing project-specific indicator data
vi. Testing changes that you believe will result in an improvement
vii. Implementing changes that work throughout the clinic

28. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
Understanding the Processes of the Underlying
System of Care
• Data may show where gaps in performance exist, but
do not explain why they exist
• Fish bone diagram
• 5 whys

29. QUALITY IMPROVEMENT IN HEALTH
SERVICE DELIVERY
Sustaining Change in Health Service Delivery
• involves continually measuring the changes produced
against improvements in service delivery that was
desired

30. National Quality Improvement Indicators
1. Adult HIV Care and Treatment Indicators
2. Paediatric HIV Care and Treatment
3. HIV exposed infant indicators
4. PMTCT Indicators

31. National Performance Measure Targets