Composite KPI is a simple tool to help hospital for conducting self assessment of quality management system to development of quality improvement of HIV care and treatment This tool was designed to help HIV/AIDS health care providers understand the4 parts of hospital accreditation (HA) standards by matching HIVQUAL-T indicators and organizational assessment results with HA each standard. The following diagram is show 4 parts of the standards..-

Standard 1 – Organization management overview
Standard 2 – Key hospital system
Standard 3 – Patients care process
Standard 4 – Organizational performance results

        However, the composite KPI is not composed all components of HA standard because limitation of existing indicators from HIVQUAL-T and organizational assessment results which are generated automatically from the HIVQUAL-T software. The main focus is on Standard 3 (Patients care process).

Usefulness of composite KPI are:

           HIV health care providers understand HA standards
           Self-assessment
           Communication between the hospital’s quality improvement staff /team and HA surveyors

Core Indicator

The example of Composite KPI score as in the excel sheet

Example of using Composite KPI in define indicators and targets on self-assessment of HIV quality improvement

Self assessment report Format

1. Quality issues/important risks: about HIV/AIDS care and treatment

Information/Indicators Target     2009 2010 2011 2012 2013
  1. Standard 1 – Organization management overview 5          
  2. Standard 2 – Key hospital system 5          
  3. Standard 3 – Patients care process 5          
  4. Standard 4 – Organizational performance results 5          

2. Context (of the facilities) such as:
     • Number of HIV patients registered for treatment
     • Main problems or challenges in HIV services

3. Process of improvement such as:
     • Participation of multidisciplinary team in HIV quality improvement
     • Measurement/monitoring methods for HIV quality improvement, comparison and implementation
     • Methods for outcome analysis of HIV quality improvement measurement, priorities and improvement planning
     • Methods for performance evaluation of quality improvement projects/activities
     • Participation of HIV patients or community in HIV services

4. Important improvement outcomes such as:
     • Results/outcomes of quality improvement projects/activities, resulting in the change of main indicator(s)
     • Innovation/new methods, tools or guidelines during the quality improvement

CQI story
     • Guidelines for writing HIV quality improvement summary report
     • Purpose:
           To record of performance that can be used in development self-assessment report for hospital accreditation
           To sharing knowledge among HIV care providers team
           To submit for presentation in conference/seminar/forum

CQI Story Format
     • Quality improvement work/project name (main project): meaningful and reflecting activities of the main project
     • Summary: brief information on the focus of the work/main project, the improvement and outcomes
     • Target: identify the indicators and main targets of the project
     • Problem and cause in brief: identify problems that need solution, effects on HIV work and treatment,
       what they are involved with and what are the root causes (from brainstorming)
     • Changes: identify the changes of each issue tested in QI program (sub project), give enough details in order to understand operational plan
       and process of changes
     • Performance measurement and changes outcome: identify the results/outcomes of each sub project and how it affects the main project,
       showing numbers and charts
     • Lessons learned: present the lessons learned from QI activities, minor activities in PDSA process, such as problems, obstacles and solution,
       innovation or tools from QI improvement activities (attach file) and suggestion for QI activities in the future.
       Thailand is an Asian country with severe affects of AIDS epidemic.


        Concept of Composite KPI for HIV quality improvement (HIVQUAL)

           Dr. Akechittra Sukkul, M.D.