1National Quality Center (NQC) NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management Plans April17, 2008 Nanette Brey Magnani and Susan.

1 National Quality Center (NQC)

NYS HIVQUAL Workshop:

A Guide for Developing Your Quality Management Plans

April17, 2008

Nanette Brey Magnani and Susan WeiglNYSDOH AIDS Institute

[email protected],[email protected]


Learning Objectives

• Understand the importance and role of a QM Plan to support ongoing QI activities

• Understand key elements of a useful written QM Plan

• Create a draft of a QM Plan update your own QM Plan

• Know where to access resources to help you make your QM Plan a working and helpful, guiding document


Agenda9:00 Welcome. Introductions

Review agenda and materials.

9:15 Interactive Presentation: A Guide for Developing Your QM Plans.Individual/dyad exercise: After each component of aQM Plan is presented, participants review examplesand highlight aspects of examples that are relevant to

them.

11:00 Cut and paste highlighted parts into a draft QM Plan.

11:30 Large group sharing and next steps.

11:50 Feedback and evaluation.

12:00 Adjourn.


Infrastructure enhances systematic implementation of improvement activities

Infrastructure


Quality Management Plan

Purpose– Provides direction of what needs to be

accomplished (goals) and how it will be accomplished (action plan) and by whom

– Sets the framework for holding the HIV program and providers accountable for the quality of patient care

– Basis for self-evaluation for next cycle of improvement


Grantee-wide Vision

Strategic QM Plan (3-5 yrs)

QM Plan

Annual Goals

Action Plan

Implementation

Annual Evaluation


Format and Components of a QM Plan

Section I: Description – Relatively unchanged from year to year

1. Quality statement

2. Infrastructure

3. Performance measurement

4. Annual quality goals

5. Stakeholder participation and development

6. Evaluation


QM Plan format and components contd.

Section II: Annual QI Action Plan– Changes from year to year

1. Presentation of data and results

2. Annual Improvement Goals/Objectives

3. QI Projects

4. Activity Timeline


How is the QM Plan written?

Decide on and systematize your approach to developing/updating your QM Plan

– An annual planning meeting

– A series of shorter meetings that could include piggybacking/using existing QM committee meetings

– Getting input (for stakeholders who can’t attend meetings due to time, distance, etc.)


(Title of Program) Quality Management Plan

Section 1: Description of ____ HIV Quality Management Program


I.1. Quality Statement

What do we want to be?

• Brief purpose/mission statement describing the end goal of the HIV quality program to which all other activities are directed

• Assume an ideal world and ask yourselves, "What do we want to be for our patients and our community?”


I.2. Quality Improvement Infrastructure

How are we organized?Leadership

Who is responsible for the program-wide quality management initiatives?

AccountabilityWho reports to whom re quality; what different committees/groups/meetings have a role in quality and how do they related to each other

Quality Committee(s) StructureMembers? Chairs? Roles? Frequency of meetings? Agendas?

CommunicationResources

Resources for the QM program? Staffing?


HIV Quality Management Committee

An HIV QM Committee oversees the quality management program. The plan usually addresses the following:

• Committee composition

• Frequency and schedule for meetings

• Plan for recording agendas, minutes, and other documentation

• Plan for consumer input


Description of QM Committee Responsibilities

• Selects an improvement process model such as HIVQUAL model and use of PDSAs

• Sets QI priorities• Recommends new policies or changes in current

policy to promote quality care• Develops, monitors, and evaluates overall QM

Program, QM Plan and Action Plan, and QI Projects.

• Provides in put on quality perspective in other planning activities (strategic planning, program development, grants)


QM Committee resp. contd

• Monitors performance measures on applicable PHS standards and on non-clinical standards related to access, linkages, services in support of clinical treatment, and/or other case management performance.

• Designs new processes, systems and procedures consistent with CQI principles and with the results of QI Projects.

• Develops a staff development plan to educate staff in quality principles and methods.

• Maintains internal and external accountability for quality management.


Quality Improvement TeamsA QI Project Team is charged to make

process improvement recommendations in the delivery of care to the HIV QM Committee.

Responsibilities:– Set improvement goals/objectives– Plan, test and measure changes– Provide progress reports to QM Committee– Manage spread of more successful change

strategies – Evaluate effort


Quality Management Organizational Chart

Organization diagram/chart depicts:– Relationships: reporting, supervisory– Internal and external linkages

It helps to see it visually and oftentimes reveals more groups and individuals that have a role or need to be involved in some way. Also, helps to expand understanding of QM Program.


Waterbury Hospital Accountability Diagram

Internal Communication

WHICH QM Committee

Ryan WhiteProgram Director

Consumer AdvisoryGroup

HIV Care Team


Plan for Communication

Internal communication (Monthly):• The QI program’s progress is on the agenda of the

monthly HIV care team and the department of medicine’s monthly meeting. Two consumers are part of the HIV care team. The QI coordinator reports to the HIV care Team on the monthly progress re implementation of the QI work plan, sharing of data on QI projects, and the formation of subcommittees, as needed, during this meeting. The Program director and the CAG representative are present during the HIV care Team meeting.


Hospital Accountability Diagram

External Communication (annually)

WHICH QI Committee

Ryan WhiteProgram Director

Dept of MedicineDirector

-HRSA-RW Part A office

Waterbury HospQM Committee

Waterbury HospExecutive

Management Team


I.3. Performance Measurement

How will we assess progress?• Identify what’s important (critical aspects

of care and services provided)

• Develop ways to measure what’s important

• Include process, outcome and satisfaction measures


I.4. Setting Annual Quality Goals

How are the annual goals determined?– What group/staff?– What data is used?– What criteria?– How often?


I.5. Stakeholder Participation and Development

How will staff, providers, consumers and other stakeholders be involved in the QM program?

• Who are they and how can they be involved in the QM Program (internal to the QM Program and external to it)

• What information do they need and when

• Provide opportunities for learning about quality improvement


I.6: EvaluationHow will we evaluate our overall performance as a program?

Infrastructure

QM Plan Elements: Evaluation

QI activities Performance Measures

•Did the QM Committee meet and oversee the QM program effectively?

•Did QI Project Teams meet their goals? Were the right staff on the teams?

•To what extent were consumers involved in the QM Program?

• Was the action plan realistic and reflective of the work of the QM Committee, QI Project Teams, & QM Program?

•To what extent were QI goals achieved? Sustained? Do the same QI Projects need to be extended?

•Was there the right mix of staff members on the QI Project teams?

•Were stakeholders informed of and participate in quality activities?

•Was training provided?

• Were performance measures reflective of standards of care?

•Were your results in the expected range?

• Were results shared with stakeholders?

• To what extent can quality reports be generated to support the QM Committee’s decisions and program monitoring?


Section II: Annual QM Program and QI Action Plan

How will we implement the QM Plan?

1. Presentation of data and results2. Annual Improvement Goals: program

level and patient care level3. QI Projects4. Activity Timeline


II.1. Presentation of Data and Data Analysis

• Data and analysis from performance measurement data (patient care)– HIVQUAL data– EHR data– Patient satisfaction surveys

• Data and analysis from QM Program evaluation– Organizational quality assessment – Feedback from staff, consumers, QI Project Teams– Disparity data– Epidemiological data


16th Street CHC HIV Program – Goal Setting

Indicator 2002 2003 2004 Goal 2005 38.9% 52.6% 80.6% Achieve 90% HIV Monitoring

CD4 VL 44.4% 44.7% 75.8%

ARV Mgt – All Trimesters

53.6% 63.2% 83.3% Maintain 83%

Adherence 100%

100% 100% Maintain 95%

94% 67% 75% QI Project 100% 88% 100% Maintain 90% 59% 94% 100% Maintain 90%

GYN exam Pap smear Gonorrhea Chlamydia 59% 94% 100% Maintain 90%

Syphilis 83.3% 86.8% 87.1% Maintain 85% Dental Exam 27.8% 10.5% 40.3% Maintain 50%

Lipid Screening 64.3% 89.5% 100% Maintain 90% Pneum. Vacc 86.1% 81.6% 100% Maintain 90%

PPD Screening 85.3% 59.5% 54.8% QI Project Substance Use

Discussed 100% 100% 100% Maintain 90%


HIV Monitoring

Monitoring and HAART Therapy

0

20

40

60

80

100

120

Pe

r c

en

t

CD4 q 4 months 60 84.4 75.6 80 84.4 81

VL q 4 months 62.2 84.4 77.8 82.2 82.2 80.2

HAART CD4 <200 73.7 69.2 100 90 91.7 85.7

HAART VL>55000 66.7 77.8 88.9 77.8 78.6 72.7

2002 2003 2004 2005 2006 2007

Core Indicator


Gynecology Exams

Gynecology Exam

0

20

40

60

80

100

120

Per

cen

t

syphilis screening 80 62.2 75.6 73.3 71.1 65.5

pelvic exam 87 67 67 76.7 69 56.5

abn pap followup 67 67 50 60 100 50

Gonorrhea culture 96 60 50 53 62 48

Chlamydia culture 96 60 50 53 62 48

2002 2003 2004 2005 2006 2007

Core Indicator


II.2. Setting Quality Improvement Goals: Program Level and Patient Care

What are the priorities for your quality program?

Quality goals are endpoints or conditions toward

which your Quality Program will direct its efforts and

resources.

There are generally two levels of improvement goals:• QM Program level

• Patient care level


QM Program Level

Based on your analysis and results of your organizational quality assessment, decide what particular aspects of your QM program can be improved during the next year.

Consider the following criteria:– What are our resources? Staff? Time?– What next steps can we take that is doable?


Example: QI Goals for Improving Infrastructure

Goal: To increase the effectiveness of the QM Program’s planning and monitoring system.

• Form a QM Committee • QM Committee meets more frequently, at least

quarterly• Write an annual QM Plan• Hold an annual planning session for the QM

Committee to discuss results of the performance measurement data and set priorities for improvement


Examples contd.

• Develop your annual QI action plan

• Establish a performance measurement system: – select measures– train staff in data collection and entry– collect data– report results


Example: Improving Patient Care

Guidelines: When determining priorities try using the following criteria when making your selections:

– Frequency: How many clients received/did not receive the standard of care/services?

– Impact: What is the effect on patient health if they do not receive this care/services?

– Feasibility: Can something be done about this problem with the resources available?


Example: QI Goals for Patient Care

• To increase the annual rate of cervical cancer screening from 43% to 72% by the end of December, 2009.

• To increase patient retention from 73% to 85% by the end of July, 2009.


QM Program Annual Action Plan

3 Goals:

• QM Program – Infrastructure

• Performance Measurement System

• Quality Improvement

Quality Management Program


Action Timeline

Goal:

Completed by

Activities/Tasks

Who

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec


Goal: Effective implementation and monitoring of

QM Program

Action Steps

Who Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Develop annual quality workplan QIC Prepare planning information (data collection, program assessment/evaluation, organizational priorities, HRSA grant)

Bonnie

Review WHIC Quality Program Plan recommendations and make changes if needed by the HIV care team

QIC

Develop Projects for WHIC annual goals: - Maintain Pt satisfaction at >95% - Repeat Quality of life survey - Consumer involvement - Improve the clinic flow

QIC

Monitor implementation of plan and revise as needed

QIC X

X

X

X

Evaluate Quality Program QI Project Team Lydia Program goals QIC Annual Organizational Assessment QIC

To be completed by 2008/09


Goal: Establish ongoing data collection and reporting to support performance measurement.

Action Steps

Who Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Determine and define quality indicators (clinical, non-clinical)

QIC

Collect and analyze data on indicators - Validate results - Review with HIV Quality Committee

Bonnie

HIV patient quality of life survey - Revise survey/decide on method

of data collection - Implement - Collect and analyze results - Determine next step

QIC

QI Project data – Prepare results of projects for planning/evaluation

- In-reach/Outreach project - Consumer QI project - PAP/STD screening - Mental Health screening - SMS program - Clinic Flow

QIC

Report results: - HIV care team - Waterbury Hospital QI annual

meeting

Lydia X

X

X

X

X

X

X

X

X

X

X

X

Evaluate effectiveness of and needs for data collection and reporting

QIC

To be completed by 2008/09


Goal: Improved quality of patient care as measured by specific performance indicators.

Completed by 2008

Action Steps

Who

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Select team membership QIC / HIV care team

Closing the loop in: - Mental Health/SA screening and

referral - Ob-Gyn referral - Nutrition

QIC

- Improve Patient Retention Bonnie Health maintenance screening:

- PAP - STD screening - Hep C and Hep B - Nutrition - CV and CKD screening

Linda

- Patient satisfaction survey Bonnie - Patient quality of life measure Lydia - Improve clinic flow Bonnie


Resources

• QM Plan Tips

• Resources (web sites, materials)


Tips on Writing a QM Plan


Part 1: Quality Statement

Tips:

• Be brief

• Be visionary

• Include internal and external expectations

• Make references to external legislative requirements on quality management


Part 2: Quality Improvement Infrastructure

Tips• Limit the length of this section (not every

detail is needed)

• Avoid naming individuals (just job functions)

• List internal and external stakeholders

• List linkages


Part 3: Performance Measurement

Tips• In developing quality indicators, remember:

– relevance– measurability– accuracy – improvability

• Include the process for reviewing and updating indicators (who/when/how)

• Include strategies to report and disseminate results and findings


Part 4: Annual Quality Goals

Tips• Pick only a few measurable and realistic

goals annually (not more than 5)

• Use a broad range of goals

• Establish targets at the beginning of the year for each goal


Part 5: Participation of Stakeholders

Tips • List internal and external stakeholders and their

functions/responsibilities• Include

– Clinical providers– Non-clinical providers– Consumers– Representatives from agency, such as hospital, network,

etc.

• List proposed training opportunities for stakeholders


Part 6: Evaluation

Tips

• Detail when and who is performing the evaluation

• Compare annual QI goals with year-end results

• Use findings to plan next year’s activities; learn and respond from past performance

• Routinely use organizational assessment tools


10 QM Plan Tips1. Do not reinvent the wheel, use

established frameworks to get started2. ‘Steal Shamelessly, Share Senselessly’3. Size does not matter!4. 80% planning, 20% writing 5. A few visionary annual goals are better

than plenty of useful ones6. Be inclusive, even it takes longer to get

your final QM plan

10 QM Plan Rules


10 QM Plan Tips (cont.)7. If you did not update the plan throughout

the year, you probably did not look at it

8. A ‘perfect’ plan is never written

9. Plans are only as good as their implementation

10.Get started! (Start a first draft. If you have one that hasn’t been updated, take it to your next QM Committee mtg)

10 QM Plan Rules


Resources

• HIVQUAL Workbook• NQC Quality Academy Online Tutorial on QM

Plans (www.NationalQualityCenter.org)• NQC QM Plan Review Checklist• Example QM Plans from others• HIVQUAL Group Learning Guide• Measuring Clinical Performance: A Guide for

HIV Health Care Providers• HRSA’s Quality Management TA Manual (9-

Step Model)


THANK YOU

Many of these materials can be sent electronically so please contact Nanette or

Susan to request them.

1National Quality Center (NQC) NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management Plans April17, 2008 Nanette Brey Magnani and Susan.

Documents

quality care

quality statement

quality principles

quality perspective

hiv quality program

qm plan section

draft qm plan

annual quality goals