Measuring Progress

Achieving success requires goals that are attainable and progress that can be monitored. Goals should be closely linked to the testing approach. Tracking data on process and outcomes is essential to refining or expanding HIV testing operations, as well as demonstrating impact and securing support from hospital leadership, policymakers, funders, and the community at large. As the program demonstrates benefit and gains resources, plans can be made to scale up the program and, in turn, set higher-level goals. This diagram depicts how the ongoing internal measurement and evaluation process cycle should progress.

What data should be collected?

At a minimum, data collected should include indicators of outcomes such as:

• Number of patients eligible for HIV testing
• Number of tests performed
• Number of reactive tests
• Number of patients that keep their initial follow-up appointment
• CD4 counts at time of diagnosis to detect at what stage of illness patients are identified in the ED

To monitor testing operations and to explain outcomes, process indicators such as these, are helpful: 

• Number of patients eligible for HIV testing
• Number of patients offered a test 
• Number of patients accepting a test 
• Number of patients who receive test results 
• Number of patients who receive confirmatory testing 
• Number of patients who receive confirmation test results 
• Number of HIV-positive patients referred to follow-up care 
• Patient perceptions and satisfaction
• Staff perceptions and satisfaction

In addition, a periodic evaluation of physical space, patient confidentiality, and turnaround times should be conducted.

What is the denominator?

The denominator should always represent the true target population for HIV testing. If a screening approach is adopted, data can be reported based on the total number of ED visits during that time period. But, if testing is limited to minor or urgent care patients, the proportion of patients tested should be calculated based on the census of urgent care patients during that period. If a risk-based approach is employed, the denominator could be the number of patients with risk or who are clinically symptomatic. Similarly, more strictly defined denominators would enable analyses to determine productivity and to identify opportunities for improvement. For example, in order to determine where to channel resources, consider how process and outcomes indicators compare across:

• Different staff conducting the test
• Testing at different times of the day, days of the week
• Testing in different settings in the ED, such as urgent care, observation, waiting rooms, triage, bedside, etc.

Resources

• Example implementation process timeline (PDF)
  Kennedy Health System Early Intervention Program
• Implementation and Effectiveness of Rapid HIV Testing Statewide at Publicly Funded Counseling and Testing Sites in New Jersey (PDF)
• Patient questionnaire: Experiences in HIV testing (DOC)
  Alameda County Medical Center
• Survey of patient attitudes toward rapid HIV testing in the ED (DOC)
  Alameda County Medical Center
• Survey of staff attitudes toward rapid HIV testing in the ED (DOC)
  Alameda County Medical Center

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Pilot Testing

Whether the program is just beginning, you are experimenting with new approaches, or you are scaling up, it is helpful to pilot your program on small scale first. Pilot testing is especially helpful when you have questions such as:

• How many patients can we expect to test in the ED (or in a particular setting in the ED)?
• What will be the impact on staff's workload or patients' flow?
• Do some staffing models work better than others in this ED?
• Do some settings work better than others for testing in this ED?

A pilot test will help demonstrate, with minimal up-front investment, what impact the program can have on a larger scale. It can also help work out any unforeseen kinks encountered in implementation.

A pilot program will be short-term—from a few weeks to a few months—and will have a targeted purpose or question it seeks to inform. Consider starting with a small group of staff who support HIV testing in the ED for this phase. At the end of the pilot, evaluate process and outcomes and make the necessary modifications before the full rollout.