comprehensive quality management plan tga qm plan.pdf · iv. quality management infrastructure the...

ST. LOUIS TGA: RYAN WHITE PART A FUNDED SERVICES CITY OF ST. LOUIS DEPARTMENT OF HEALTH

HIV/AIDS CARE SERVICES

Revised March 4, 2010

CCOOMMPPRREEHHEENNSSIIVVEE QQUUAALLIITTYY MMAANNAAGGEEMMEENNTT PPLLAANN

1

Image extracted from the Yuma, AZ Community Development Website.© 1997-2009 City of Yuma. All rights reserved.

TABLE OF CONTENTS

I. Introduction .......................................................................... 2

Legislative Requirement..............................................................2 Definition of Quality ...................................................................2 HRSA/HAB Expectations .............................................................2

II. Quality Statement ................................................................. 3 III. Quality Methodology ............................................................. 4 IV. Quality Infrastructure ........................................................... 5

Leadership ................................................................................6 Roles and Responsibilities ...........................................................6 Resources .................................................................................7 Quality Partners .........................................................................7

V. Performance Measurement................................................... 8 VI. Annual Quality Goals............................................................. 9 VII. Capacity Building ................................................................ 10 VIII. Evaluation............................................................................ 12 IX. Meeting and Reporting Schedule ....................................... 14

ATTACHMENTS:

Quality Indicators ...........................................................................A Data Collection Plan........................................................................B Technical Assistance Request Form ............................................... C Education & Training Schedule.......................................................D NQC Part A Quality Assessment Tool ............................................. E HIVQUAL QI Project Assessment Tool ........................................... F 2009 -2010 Implementation Plan ..................................................G

Comprehensive QM Plan

i

I. Introduction

Legislative Requirement:

The Ryan White Treatment Extension Act of 2009, Part A requires each EMA/TGA to establish a clinical quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV/AIDS and related opportunistic infection, and as applicable, to develop strategies for ensuring said services are consistent with the guidelines for improvement in the access to and quality of HIV health services.

Definition of Quality:

Quality is defined by the HIV/AIDS Bureau Division of Service Systems (HAB/DSS) as the degree to which a health or social service meets or exceeds established professional standards and user expectations. In order to constantly improve systems of care, quality programs should continuously assess:

The quality of inputs The quality of the service delivery process, and The quality of outcomes.

HRSA/HAB Expectations: The Ryan White HIV/AIDS Program places major emphasis on enhancing the quality of care for people living with HIV/AIDS (PLWH/A). According to the Managers' Statement in the Ryan White HIV/AIDS Program Amendments of 2000, clinical quality management programs are expected to:

1. Assist Ryan White HIV/AIDS Program-funded medical providers to ensure services provided adhere to established HIV treatment guidelines to the extent possible

2. Ensure that strategies for improving medical care include health-related supportive services that enhance access to care and adherence to HIV medical regimens, and

3. Ensure that available demographic, clinical, and health care utilization information is used to monitor HIV-related illnesses and trends in the local epidemic.

A successful clinical quality management program should:

Be a systematic process with identified leadership, accountability, and dedicated resources available to the program.

Use data and measurable outcomes to determine progress toward evidenced-based benchmarks.

Focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement.

Be a continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities.

Ensure data is fed back into the quality improvement process to ensure that goals are accomplished and improved outcomes are realized.

Comprehensive QM Plan 2

II. Quality Statement: Vision, Mission & Purpose

The aim of the St. Louis TGA Quality Management (QM) program is to ensure a collaborative path toward sustainable improvements in the delivery of RW Part A funded medical and support services throughout the region. To that end, the City of St. Louis Department of Health (DOH) Grants Administration (GA) division is committed to working in collaboration with our community partners to achieve the following vision, mission, and purpose: Vision: We envision a 100% accessible continuum of high quality care and support to aid in the elimination of health disparities among PLWH/A. Mission: To continuously assess the impact and extent to which Ryan White, Part A funded core medical and supportive services are provided for PLWH/A in the St. Louis TGA; ensure consistency with Public Health Service/HIVQUAL guidelines for the treatment of HIV/AIDS and related opportunistic infection; and as applicable, collaborate to design and implement TGA-wide process changes geared toward improvement. Purpose of the QM Program:

Support the development of higher quality care for people living with HIV/AIDS

Demonstrate program value quantitatively by linking outputs (amounts of services provided) to outcomes (results)

Identify and justify critical program activities and resources required to meet needs

Enable local HIV service delivery networks and providers to perform better and to function as a system

Providing improved access to and retention in care for HIV-positive individuals aware of their status

Enhancing the quality of services and client outcomes

Linking social support services to medical services

Making program changes to respond to the evolving epidemic

Using epidemiologic, quality, and outcomes data for planning and priority setting

Ensure accountability


III. Quality Methodology

The pursuit of quality is rooted in a binary process of performance measurement and process modification. The interdependent phases of measurement and modification begin with Quality Assurance (QA). QA refers to a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards and identifying opportunities for improvement. The second phase of the cycle is referred to as Quality Improvement (QI). QI is characterized by the conceptualization and trial of process modifications aimed at enhancing performance. When routinely carried out and integrated throughout a continuum of care, QA and QI result in a continuous quality improvement (CQI) approach to total quality management (TQM). TQM is the driving force behind the St. Louis TGA QM program and the HIVQUAL model that guides the region’s improvement efforts. Developed by the New York State Department of Health AIDS Institute, the HIVQUAL framework for QI in HIV care is an evidence-based, step wise methodology characterized by the following interconnected cycles: Program Cycle: The program cycle places emphasis on the activities necessary to build

and sustain an HIV-specific quality infrastructure, including:

Develop and plan a QM program Facilitate Implementation of HIV QM program Evaluate and revise HIV QM program

Project Cycle: The project cycle focuses on methodically selecting areas for

improvement based on the goals and objectives conceived during the program cycle. Once areas of improvement are selected, project teams are formed to:

Investigate the process Plan and Test changes (PDSA) Evaluate results with key stakeholders Systematize changes

Each cycle of the HIVQUAL improvement process is accompanied by a plethora of tools designed to aid in the planning, execution, and evaluation of QI activities. To ensure successful implementation and continuation of the HIVQUAL methodology, the St. Louis TGA QM program features a multi-level infrastructure to provide for administrative oversight of the program cycle and a collaborative approach to the project cycle as described in the next section.


IV. Quality Management Infrastructure

The St. Louis TGA QM program features a two-tier broad organizational structure supportive of system level and process level performance measurement and improvement. At the system level, the Grants Administration Quality Management (GA QM) team facilitates the program cycle of the HIVQUAL model. To expedite the project cycle of the HIVQUAL model, the team commissioned a Transitional Grant Area Quality Management (TGA QM) committee. Together, the GA QM team and multidisciplinary TGA QM committee represent every faction of our system and are explained in more detail under the Roles and Responsibilities heading on page 6. At the process level, each RW Part A-funded service provider is contractually required to have a functioning QM program and written QM plan in place. To ensure compliance with this directive, members of the GA QM team monitor provider quality efforts relative to their functional area. For example, the Contract Compliance Officer (CCO) monitors all supportive service contracts. Subsequently, the CCO must ensure said providers have written QM plans in place supportive of TGA-wide quality goals and objectives. The aggregate quality data obtained via the program monitoring process is shared with the TGA-wide QM committee to assess the impact of process level improvements or lack thereof at the system level. The TGA QM program infrastructure is illustrated below in Figure 1.

GA QM Team

TGA QM Committee system level

Grant Administrator

Contract Compliance

Officer

Health Care Compliance

Officer

Case Mgt. Coordinator

Program Specialist II

Admin Assistant

Service Provider(s) process level

LTC Case Mgr.

QI Project QI Project QI Project QI Project

Figure 1: St. Louis TGA QM Program Infrastructure


Leadership: The Grants Administrator is ultimately responsible for all quality related activities and allocates fiscal and human capital to support the GA QM team and TGA QM Committee. The GA QM team meets monthly and is accountable to HAB/DSS and the Metro St. Louis HIV Health Services Planning Council (PC). The Grants Administrator is responsible for reporting the status of the QM program to the department’s DSS Project Officer during their monthly conference call. The GA QM team is responsible for reporting the status of the QM program to the Planning Council and appropriate subcommittees on an annual basis. The quality roles and responsibilities inherent in the GA QM team and TGA QM committee are detailed in the following section. Roles and Responsibility: GA QM Team: The GA QM team is authorized to plan, implement, and evaluate the TGA QM program. The team is ultimately responsible for coordinating and documenting quality activities; creating a feedback loop; and building sustainable quality partnerships at the national, state, and local levels. Team members are appointed by the Grants Administrator based on their current job classification. Eligible job classifications and their respective QM related tasks include: Grants Administrator (GA): Provides general oversight of the QM program and budget.

Contract Compliance Officer (CCO): Conducts remote and on-site program monitoring for supportive service providers to ensure compliance with RW standards of care and other relevant federal, state, and local regulations. Develops, implements, and oversees a structured, system-wide approach for planning, executing, and evaluating QI efforts among Part A support service providers.

Health Care Compliance Officer (HCCO): Conducts remote and on-site program monitoring visits for core medical service providers to ensure compliance with RW standards of care and other relevant federal, state, and local regulations. Performs clinical chart audits; develops, implements, and oversees a structured, system-wide approach for planning, executing, and evaluating QI efforts for 11 primary care sites in MO; and partners with the Southern Illinois Healthcare Foundation (Part C) quality manager to stay abreast of the Illinois’ client level clinical outcomes.

Case Management Program Coordinator (CMPC): Conducts remote and on-site program monitoring visits for medical case management service providers to ensure compliance with RW standards of care and other relevant federal, state, and local regulations. Facilitates medical case management chart audits and client satisfaction measurement; obtains quality data relative to MCM indicators; develop, implement, and oversee a structured, system-wide approach for planning, executing, and evaluating QI efforts among Part A medical case management service providers.

Program Specialist II (PSII): Collects, analyzes, and distributes quality data/reports to the appropriate staff member.


TGA QM Committee: The TGA QM committee is chaired by the CCO/HCCO and reflects the diversity of RW Part A stakeholders. The committee is commissioned to establish a set of TGA-wide quality goals and desired outcomes, develop performance indicators and measurement timeline, review aggregate quality data, identify opportunities for system level improvement, and deploy cross functional QI teams to investigate root causes and test changes. In the best interest of a collaborative approach to QI, the committee must maintain membership representative of the following: Consumers Part B Representative (MO/IL) Contractors/Service Providers Part C Representative (MO/IL) Planning Council Support Staff Part D Representative (MO/IL)

Resources: Financial Resources: In accordance with section 2604(h)(5) which authorizes Part A funding for clinical quality management activities, the Grants Administration will continue to set aside the lesser of 5 percent of amounts received under the grant; or $3,000,000 to support the achievement of annual quality goals. Quality Partners: Statewide QM Committee: The MO Statewide Quality Management Team is comprised of Ryan White Part A, B, C and D Grantees from across the state. The group meets at least once a year to establish quality goals and measures. These goals are then tracked and reported on by the Ryan White Part B Director through conference calls and/or meetings. The GA is responsible for attending all Statewide QM committee meetings. In the event the GA is unable to attend, a member of the GA QM team will be assigned to attend in her absence. Midwestern Regional QI Team: The Midwestern Regional QI Team is a multi state cross part collaborative focused on QI in Kansas, Missouri, and Iowa. The CCO is responsible for participating in all Midwestern Regional QI Team meetings, webex trainings, and conference calls. In the event the CCO is unable to attend, a member of the GA QM team will be assigned to participate in her absence.


V. Performance Measurement:

Performance measurement is the cornerstone of the St. Louis TGA QI process. As such, the GA QM team will work with the TGA QM committee to define indicators that measure the system’s conformance with PHS guidelines for the treatment of HIV/AIDS and applicable Standards of Care. Of the indicators defined, only those deemed the most relevant, measurable, improvable, and accurate will be retained and monitored. Selected indicators must be categorized and documented in the following format:

Example

St. Louis TGA QM Program Quality Indicators Indicator Type Number Indicator Definition Desired

Direction Target

1

Pap smear: % of sexually active female patients of child bearing age with evidence of an annual pelvic exam/Pap smear.

90% Gynecological

Care

2

Gonorrhea Culture: % of sexually active female patients of child bearing age with evidence of an annual gonorrhea culture.

90%

3 CD4 Count: % of patients with a documented CD4 cell count test performed every four months.

95% HIV Monitoring

4 Viral Load: % of patients with a documented viral load test performed every four months.

90%

Equipped with a mutually agreed upon set of quality indicators, the GA QM team and TGA QM committee will develop a data collection plan to ensure performance measures/indicators are uniformly gathered and reported. The data collection plan must be maintained in the following format:

Example

Data Collection Plan Indicator Type Quality of Care

Indicator Data Source Collection Method Collector

Gynecological Care

Pap smear Chart Audits Annually with HIVQUAL

chart audit tool. HCCO

HIV Monitoring CD4 Count FACTORS Quarterly HCCO Selected quality indicators (Attachment A) and the corresponding data collection plan (Attachment B) and are updated annually. In most cases the GA QM team will be responsible for data collection and reporting. Performance data will be shared with the TGA QM committee to aid in the identification of opportunities for improvement and development of annual quality goals.


VI. Annual Quality Goals: 2009 - 2010

Quality goals are endpoints or conditions toward which the QM program will direct its efforts and resources during quality improvement work. The GA QM team will work with the TGA QM committee to develop annual goals to guarantee they are understood and embraced at the system level. The goal identification process will be data driven to ensure the team focuses on the most critical program areas. The following criteria will be used prioritize annual quality improvement goals:

1. Frequency: How many patients received and how many did not receive the standard of care? 2. Impact: What is the effect on patient health if they do not receive this care? 3. Feasibility: Can something be done about this problem with the resources available?

Due to budgetary and time constraints, the top five priority goals will be selected for GA funded QI projects during a given grant year. Considering the bulk of the St. Louis TGA’s RW Part A funds are expended on core medical services, a minimum of three goals must be directly linked to improved health outcomes. The remaining two goals should focus on improving supportive services which may be directly or indirectly linked to improved health outcomes. All quality goals must be linked to a specific element of care/funded service category, have an agreed upon threshold/target, and quality of care indicator. Quality goals will be updated annually and maintained in the following table.

2010 - 2011 Quality Goals I. Goal: Element of HIV

Care HIVQUAL Top 10%

Baseline

Target Quality of Care Indicator(s)

II. Goal: Element of HIV


Baseline


III. Goal: Element of HIV


Baseline


IV. Goal: Element of HIV


Baseline


V. Goal: Element of HIV


Baseline



VII. Capacity Building

Success of the St. Louis TGA QM program is heavily dependant upon the success of our community partners and their inherent ability to deliver quality medical/supportive services for PLWHA. To that end, the GA QM team is dedicated to ensuring all of our community partners have the capacity and capability to influence and sustain quality improvements. The team will facilitate the capacity building process through the development and implantation of the following: Capacity Assessment: Grants Administration will conduct an annual QM Capacity Building Survey. Survey results will guide the development of education and training opportunities offered in large group settings. The findings will also afford the GA QM team an opportunity to proactively offer technical assistance on an agency by agency basis. Technical Assistance: Each member of the GA QM team is available to offer QM related technical assistance relative to their functional area. Requests for technical assistance must be submitted in writing via the “Technical Assistance Request Form” (Attachment C). The form must be emailed to the Contract Compliance Officer at [email protected]. Approved request for TA will result in on/off-site consultations aimed at: Identifying where the provider is in the QM program life cycle:

o Planning o Design o Implementation o Deployment and maintenance

Assessing where the provider is in comparison to where they should be. Developing and executing an action plan to bridge the aforementioned gap. Follow-up

Education/Training Opportunities: The GA QM team will host a minimum of four innovative QM training sessions per year. Session topics will correlate to the most frequently cited capacity issues as identified during the capacity assessment process. The education and training schedule (Attachment D) will be updated annually and distributed to all of our community partners. The team will also market other local, state, and national QM training opportunities as the information is received.


mailto:[email protected]

Multimedia Quality Publications: As evidenced in the complexity of this QM plan, the road to quality improvement in HIV care is well traveled and littered with best practices. Versus sending our community partners on a scavenger hunt for quality data, success stories, and related resources, the GA QM team will publish and distribute a quarterly newsletter, host a social networking site, and ensure access to National Quality Center, HIVQual, and other resources relevant to the advancement of QI in HIV care. A brief description of our QM communication tools appears below: Quality Counts! is a quarterly newsletter published by the Grants Administration division of the City of St. Louis Department of Health. The goal of the publication is to share best practices, quality dashboards, and provide a public forum to congratulate successful QI teams. All of our community partners are eligible to forward submissions for the publication.

QUALbridge is a social networking site designed to connect local quality professionals and provide around the clock access to quality information. All of our community partners are eligible to join the network and maintain a personal (agency) page.

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VIII. Evaluation

The St. Louis TGA QM program will be evaluated at the administrative, system, and provider levels on an annual basis. Administrative Evaluation Process: The GA QM team will utilize the NQC Part A quality assessment tool (Attachment E) to annually assess the administration and facilitation of the QM program as a whole. The tool is designed to evaluate the following: Quality Structure Quality Improvement Activities Quality Planning Staff Involvement Quality Performance Measurement Clinical Information System

The tool will be completed by each member of the GA QM team and TGA QM committee. An average of the individual scores will be used as the final score. System Level Evaluation Process: The TGA QM committee will utilize the HIVQUAL QI project assessment tool (Attachment F) to assess project team approach to improving the delivery of care/support for HIV patients. The tool is designed to assess three key aspects of QI project team work: Goal Achievement Interventions Teamwork

The tool will be completed for each project team by each project team member. An average of the individual scores will be used as the group’s final score. Service Provider Evaluation Process: All RW Part A-funded service providers are contractually required to have a functioning QM program and written QM plan in place. Performance related to this requirement is assessed during biannual site visits. Specifically, each member of the GA QM team monitors subcontractors and service providers relative to their assigned service categories. This includes revising and implementing program monitoring tools based on HRSA’s guidelines for the RW Part A program, standards of care, and public health service guidelines. The monitoring tools are designed to evaluate a given service provider’s performance in the areas of fiscal management, program management/service delivery, and QM.


Process to Update the QM Plan The process to update the QM plan is driven by the results of the aforementioned evaluations. Aggregate scores for each assessment – administrative, project team, and service provider – are shared with the TGA QM committee. The committee uses the information to in conjunction with other relevant quality data (performance measures) to identify quality goals for the upcoming grant year and suggest changes in the QM program/plan. The GA QM team is responsible for implementing said changes and distributing the updated QM plan to stakeholders.

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IX. Meeting and Reporting Schedule

GA QM Team Meeting and Reporting Schedule: The GA QM team will meet the first Wednesday of every month. QM will remain a standing topic on the department’s weekly staff meeting agenda. The Grants Administrator will report QM/QI activities to the region’s DSS Project Officer on the second Tuesday of every month. The Contract Compliance Officer will report QM/QI activities to the Planning Council on a biannual basis (April and January). TGA QM Team Meeting and Reporting Schedule: The TGA QM committee will meet on a quarterly basis. The actual date of the meeting will be discussed and decided upon by the committee to ensure attendance and participation. The 2010 – 2011 TGA QM Committee meeting schedule is as follows: Month Meeting Purpose March Review 2009/2010 Performance Data

Identify Quality Goals for the grant year Select Indicators Draft Data Collection Plan Organize QI Project Teams

June QI Project Teams Report Findings/Progress Committee Provide Feedback/Suggestions to Systematize Improvements

September QI Project Teams Report Findings/Progress Committee Provide Feedback/Suggestions to Systematize Improvements

December QI Project Teams Report Findings/Progress Committee Members Complete HIVQUAL Organizational Assessment Tool Review Aggregate QI Project Assessment Findings Discuss Barriers to Change CELEBRATE SUCCESS!

TGA QI teams will meet more frequently to strategize, test, and implement changes. Each team will develop their respective meeting schedules and project charters. Service Provider Meeting and Reporting Schedule: As previously mentioned, each Part A service provider is contractually required to have an operating QM program supported by a written QM plan. Each provider’s QM plan must include a meeting and reporting schedule. Provider QM teams/committees must meet at least monthly. Their meeting agendas and minutes should be submitted to Grants Administration as an attachment to monthly invoices. Providers will also be required to submit QI project reports as an attachment to their quarterly reports.


ATTACHMENTS


Attachment A: Quality Indicators by Service Category

St. Louis TGA Quality Indicators 2010 - 2011

Service Category

HIV Care Service

Element of Care

Service

Indicator Definition Desired Direction

Target

HIV Care

Medical Case

Management

Core Medical

Medical Nutrition Therapy

Housing

Support Services

Food Bank


Attachment B: Data Collection Plan

2010 – 2011 Data Collection Plan Indicator

Type Quality of

Care Indicator

Data Source

Collection Method/Tool Frequency Collector


Attachment C

TA Request Form

1

Please provide a rationale for requests with an anticipated timeline extending beyond a 6 month timeframe. If less than 6 months please type N/A in the shaded area below.

Date of Request: / /

****Type information in the shaded areas and email form to [email protected].****

Agency:

Quality Contact: Street Address:

City: State: Zip:

Email: Phone:

HIV/AIDS Funding: Ryan White Part A MAI HOPWA (check all that apply)

Number of Unduplicated Clients Served to Date (RW Part A):

Please describe the nature of your TA request:

TA Preference:

On-site

Off-Site via conference calls/email TA Time Frame:

1-3 Months 3-6 Months 6-9 Months 9-12 Months

Please indicate what your organization intends to achieve as a result of the requested TA:

Quality Management TA Request Form

Attachment C

TA Request Form

2

For Internal Use Only:

Request RCVD: / / Request Assigned To: / / Date TA Request Processed: / / Approved: Yes NO Rationale if TA request is NOT approved: Signature of Approval:

Date TA Request Closed: / / Comments: ****File completed an electronic copy of this form in the agency’s folder on the G drive and file a hard copy in the agency’s correspondence folder.****

Attachment D: Quality Management Education and Training Schedule

The 2010 – 2011 Education and Training Schedule is based on the results of the 2009 QM Assessment. Official registration forms for the trainings listed in the table below will be distributed 30 days prior to the scheduled event. The registration form will be accompanied by a narrative description of the training session detailing date, time, duration, and location; facilitator bios; required prework; and links to relevant documents.

2010 - 2011 Quarter QM

Topic Target

Audience Training Objectives Facilitator (s) RSVP Instructions

1 How To Build a Sustainable Quality Management Infrastructure.

Clinical and Non-clinical HIV Service Providers

1) Educate Service providers about the importance of QM in HIV Care. 2) Build service provider’s capacity to develop and implement an effective QM Program within their organization.

Stephanie D. Bogan Quality Assurance/CCO City of St. Louis DOH

Complete and return registration form to [email protected] Due Date Indicated on Form

2 How To develop and implement a written QM plan.


1) Build service provider’s capacity to develop and implement a written QM. 2) Equip services providers with the necessary tools to develop and evaluate a written QM plan.



3 Selecting HIV Quality Indicators and Collecting Performance Data


1) Equip service providers with the skills needed to accurately identify and define quality indicators. 2) Build service providers’ capacity to develop and execute meaningful data collection plans.


& Jacob C. Fisher Data Specialist/PS II City of St. Louis DOH

TBA Complete and return registration form to [email protected] Due Date Indicated on Form

4 Quality Improvement for Medical Case Mangers.

Case Mgt. Supervisors Medical Case Managers LTC Case Managers

1) Educate Case Mangers about the importance of QM in HIV Care. 2) Build Case Managers’ capacity to organize and execute meaningful QI projects.

Stephanie D. Bogan Quality Assurance/CCO City of St. Louis DOH & Bobie Williams MCM Prgm. Coord. City of St. Louis DOH







NQC Part A Quality Management Program Assessment Tool

TA Guidelines Page 4.4 Developed by the National Quality Center (NQC) revision 2.0 10/15/06

EMA/TGA: Contact Person:

City: State: Zip Code:

Address:

Phone: Fax: Email:

Quality Management Plan

A.1. Is a comprehensive HIV-specific, EMA/TGA-wide quality management plan in place with clear definitions of leadership, roles, resources and accountability?

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5

Score 0 Part A program has no or minimal written quality plan in place; if any in existence, written plan does not reflect current day-to-day operations.

Score 1 Part A program has only loosely outlined a quality management plan; written plan reflects only in part current day-to-day operations.

Score 2

Score 3 A written EMA/TGA-wide quality management plan is developed describing the quality infrastructure, frequency of meetings, indication of leadership and objectives; the quality plan is shared with staff; the quality plan is reviewed and revised at least annually; some areas of detail and integration are not present.

Score 4

Score 5 A comprehensive and detailed HIV-specific, citywide quality management plan is developed/refined, with a clear indication of responsibilities and accountability, quality committee infrastructure, outline of performance measurement strategies, and elaboration of processes for ongoing evaluation and assessment; engagement of other department representatives is described; quality plan fits within the framework of other citywide QI/QA activities; staff and providers are aware of the plan and are involved in reviewing and updating the plan.

Comment:

A.2. Are appropriate performance and outcome measures selected, and methods outlined to collect and analyze EMA/TGA performance data?


Score 0 No appropriate performance or outcome measures are selected; methods to collect and analyze EMA/TGA-wide performance data are not outlined.

Score 1 Only those indicators are selected that are minimally required; no process takes place to annually review and update indicators and its definitions; methods to collect data are not described.

Score 2

Score 3 Selection of indicators is based on results of past performance data and some input of Title I representatives; indicators include appropriate clinical or support service measures; indicators



reflect accepted standards of care; indicator information is shared with Part A staff and providers; processes are outlined to measure and analyze EMA/TGA-wide performance data.

Score 4

Score 5 Portfolio includes clinical and support service indicators with written indicator descriptions; measures are annually reviewed, prioritized and aligned with Part A quality goals; all indicators are operationally defined, and augmented with specific targets or target ranges, including desired health outcome; EMA/TGA performance measurement activities include partnering with other data sources; EMA/TGA-wide data collection plans are clearly outlined and strategies to analyze data are detailed.

Comment:

A.3. Does the work plan specify timelines and accountabilities for the implementation of the EMA/TGA-wide quality of care program?


Score 0 No work plan is specified for the implementation of the Part A quality of care program. Score 1 A work plan is only loosely outlined; no specific timelines for the implementation of the quality

of care program are established; no formal process to assign timelines and responsibilities; follow-up of quality issues only as needed.

Score 2 Score 3 A written, annual work plan which outlines the implementation is in place; timetable is shared

with appropriate staff; updates in the work plan are discussed in quality committee(s); quality activities are planned before execution.

Score 4 Score 5 A process to assign timelines and responsibilities for quality activities is in place and clearly

described; annual plan for resources is established; Program A staff are aware of timelines and responsibilities; quality committees are routinely updated and consulted on the implementation of the EMA/TGA-wide quality program.

Comment:

Organizational Infrastructure

B.1. Does the Part A program have an organizational structure in place to oversee planning, assessment and communication about quality?


Score 0 No quality structure is in place to oversee planning, assessment and communication about quality.

Score 1 Only a loose quality structure is in place; a few representatives are involved; knowledge of quality structure among staff is limited.

Score 2 Score 3 Senior EMA/TGA representative heads the HIV quality program; provider representatives are

represented in the HIV quality structure; findings and performance data results are shared; staff for the quality program is identified; resources for the quality program are made available.



Score 4 Score 5 Senior leaders actively support the program infrastructure and planned activities; key staff are

identified and supported with adequate resources to initiate and sustain quality improvement activities at the EMA/TGA program as well as the provider level; Part A staff is routinely trained on quality improvement tools and methodologies; findings and performance data results are frequently shared internally and externally.

Comment:

B.2. Is a quality management committee with appropriate membership established to solicit quality priorities and recommendations for quality activities?


Score 0 No Part A quality management committee is established to solicit quality priorities and recommendations for quality activities.

Score 1 Quality meetings are held with only a few EMA/TGA representatives and/or provider representatives; ad hoc meetings are only used to discuss immediate issues.

Score 2 Score 3 Quality committee is established that engages various representatives; routine quality committee

meetings are held to solicit quality priorities and recommendations for quality activities; reporting of committee updates in place.

Score 4 Score 5 Senior leader, key Part A providers and consumer representatives are actively involved in

quality committee(s) to establish priorities and solicit recommendations for current and future quality activities; membership is reviewed and updated annually; HIV quality meetings include written minutes and reporting mechanisms.

Comment:

B.3. Does the Part A quality program involve providers, consumers and representatives from other Ryan White Program Parts?


Score 0 Part A quality program does not involve providers, consumers and representatives from other Ryan White Program Parts.

Score 1 Part A quality program includes only internal EMA staff, with limited input from other groups; neither Part A providers nor consumers are involved.

Score 2 Score 3 Part A providers and at least one consumer representative are participating in quality committee

meetings; other Ryan White Parts are involved. Score 4 Score 5 Part A providers and consumers are actively engaged in the EMA/TGA-wide quality of care;

representatives from other Ryan White Parts are structurally integrated in the quality program. Comment:



B.4. Are processes established to evaluate, assess and follow up on HIV quality findings and data being used to identify gaps?


Score 0 Processes are not established to evaluate, assess and follow up on HIV quality findings. Score 1 No processes are established to evaluate the HIV quality program; quality infrastructure and its

activities are only reviewed only if necessary; when establishing/updating the annual work plan, past performance is not considered; quality of care program does not learn from past successes and failures.

Score 2 Score 3 Review process is in place to evaluate the Part A quality infrastructure, and assess the

performance data; findings are generated for follow up and used to plan ahead; summary of findings are documented.

Score 4 Score 5 Process to annually assess effectiveness of HIV quality program; data findings are used to

identify gaps in care and service delivery; staff is actively involved; assessments and follow ups are documented; HIV leadership is well aware and involved in evaluation of HIV quality program; findings and past performance scores are used to facilitate and shape Part A quality program.

Comment:

Implementation of Quality Plan and Capacity Building

C.1. Are appropriate performance data collected to assess the quality of HIV care and services EMA/TGA-wide?


Score 0 No performance data are collected to assess the quality of HIV care and services EMA/TGA-wide.

Score 1 Basic performance measurement systems are in place; only utilization data are collected; no process established to share data or only used for punitive purposes; data are not collected EMA/TGA-wide.

Score 2 Score 3 A system to measure key quality aspects among Part A providers is established; data are

collected, analyzed and routinely disseminated to providers; data are collected from most providers in the EMA/TGA.

Score 4 Score 5 The quality, including clinical and support services across the EMA/TGA, is measured by

selected process and include outcome measures; organizational assessments of Part A provider quality infrastructures are conducted; results and findings are routinely shared with providers to inform and foster quality improvement activities; data are collected from all Part A providers.

Comment:



C. 2. Does the Part A quality program conduct quality improvement projects to improve systems and/or quality of care issues?


Score 0 The Part A quality program does not conduct quality improvement projects to improve internal systems and/or quality of care issues.

Score 1 Quality improvement activities focus on individual cases or incidents only; projects are primarily used for inspection; selection of quality activities is done by single person.

Score 2 Score 3 A few staff members have input in the selection of quality projects; quality improvement

activities focus on issues related to structures and processes only; at least one quality project was conducted in the last 12 months to improve systems and/or quality of care issues; internal Part A quality improvement activities are tracked.

Score 4 Score 5 Structured process of selection and prioritization of quality projects is in place; quality

improvement projects are informed by the data and are outcome related; staff is involved in quality improvement projects; findings are routinely shared with entire staff, presented to the quality committee, and used to inform subsequent projects.

Comment:

C.3. Does HIV quality program offer QI training and technical assistance on quality improvement to Part A providers?


Score 0 The quality program does not offer QI training and/or technical assistance on quality improvement to Part A providers.

Score 1 No structured process in place to train Title I providers on quality improvement; limited technical assistance resources available for Part A providers to build capacity for quality improvement.

Score 2 Score 3 Capacity to train Part A providers and provide technical assistance on quality improvement is

available; process in place to triage TA requests from individual providers; some resources are available and mostly used in response to TA requests.

Score 4 Score 5 A quality workshop program is established to routinely train clinical and service providers on

quality improvement priorities, tools and methodologies; an annual training schedule is developed with quality topics based on needs assessment including input by providers; trainings are well attended and evaluations are routinely kept and analyzed and used to improve future training; technical assistance is provided to clinical and service providers through on-site visits by quality experts.

Comment:

Attachment F

HIVQUAL QI PROJECTASSESSMENT TOOL

Evaluation Question Directions Goal Attainment Score To what extent did the QI team meet its goal?

Compare the QI project goal with: Baseline data Pilot test results Follow-up measurement data

What resources were needed to achieve the goal?

Time Investment (# of team meetings multiplied by the average duration of said meetings)

Cost (avg. hourly salary multiplied by time investment then add figure to any additional monetary investments, i.e. materials.)

In hindsight, was there a more efficient way to attain the goal?

Compare the expected vs. actual resources needed to attain said goals

Monitor data on QI indicators following project completion

Interventions: Score How effective were the changes over the short term?

State degree of goal attainment Describe interventions

Was the team able to systemize changes?

Describe the extent to which the program or other parts of the organization were involved in the interventions (e.g., staff; policy changes etc.)

How did program staff respond to systematization?

Staff attitudes toward the intervention; reasons why favorable or unfavorable.

Teamwork: Score Was the team strategically positioned to attain their stated goals?

List team members by name and title. Assess the level of diversity in

professional functions and detail if the aforementioned was supportive of the QI project.

Were team members adequately prepared to develop, test, and implement changes?

Describe project results and the degree of goal attainment

Previous exposure and training in QI Degree of comfort with QI tools

How effective were team meetings?

Quantity of Team Meetings o Number of Team Meetings o Frequency of Team Meetings o Avg Length of Team Meetings

Quality of Team Meetings o Review meeting agendas/minutes

Scale 1 = Poor 5 = Excellent

QI Project Assessment Tool

Attachment G: 2009 – 2010 QM Program Implementation Plan


Goal: Establish An Effective Quality Management Program 2009/2010 Activity Who Mar Apr Mar June July Aug Sept Oct Nov Dec Jan Feb Reconvene the St. Louis TGA QM Committee

Laura Due

Hire additional QM Staff (CCO and CMPC)

Amber x Due

Train CCO (NQC TOT/TQL) NQC

(ongoing) TOT TQL

Train GA QM Team Stephanie (ongoing)

x x x x x x x x x x x x

Train TGA QM Committee Stephanie (ongoing)

x x x

Restructure QM Program Stephanie x x Due Draft QM Plan Stephanie x x Due Draft Implementation Plan Stephanie x x Due

Internal QM Plan Review/Edit GA QM Team

x Due

External QM Plan Review/Edit TGA QM

Committee x Due

Select 2010/2011 Quality Goals TGA QM

Committee x ue D

Draft 2010/2011 Data Collection Plan

TGA QM Committee

Apply for Technical Assistance Implementing the approved QM Plan

Stephanie (NQC)

D ue

Monitor Implementation of TGA QM Plan

GA QM Team


Attachment G: 2009 – 2010 QM Program Implementation Plan

Goal: Establish Ongoing Data Collection and Reporting To Support Performance Measurement 2009/2010 Activity Who Mar Apr Mar June July Aug Sept Oct Nov Dec Jan Feb Identify and Define 2010/2011 Quality Indicators for each funded service category (HIVQUAL US/NYC Dept. of Health)

TGA QM Committee x x ue D

Draft 2010/2011 Data Collection Plan

TGA QM Committee x x ue D

Train Data Abstractors Stephanie/Jake x Collect Clinical Quality Data HCCO/Jill x x x Due Collect non-clinical Quality Data Stephanie x Collect Case Management Quality Data Bobie x Due

Collect Client Satisfaction Data GA QM Team x Due Analyze All QM Data – Present Finding to TGA Committee and Planning Council (as noted in QM Plan)

GA QM Staff x x Due

Identify Areas For Improvement and Organize 2010/2011QI Project Teams

TGA QM Committee D ue

comprehensive quality management plan tga qm plan.pdf · iv. quality management infrastructure the...

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