Back to Basics – QI 101 December 19, 2013 Presenters: Jane Caruso – NQC Coach Kevin Garrett – NQC Senior Manager

2National Quality Center (NQC) Quality Improvement 101 Annual Quality Management Plan

3National Quality Center (NQC) Quality Management Plan Purpose  Provides direction of what needs to be accomplished (goals) and how it will be accomplished (workplan)  Clear indication of who is responsible  Sets the framework for holding grantee and providers accountable for its accomplishments  Basis for self-evaluation for next cycle of improvement

4National Quality Center (NQC) Key Elements of a Quality Management Plan 1.Quality statement 2.Quality improvement infrastructure 3.Performance measurement 4.Annual quality goals 5.Participation of stakeholders 6.Evaluation 7.Workplan/Implementation Plan

5National Quality Center (NQC) NQC QM Plan Checklist

6National Quality Center (NQC) Overview of Quality: Quality Management Program Elements – QM Committee

7National Quality Center (NQC) The Quality Management Committee: Builds the HIV program’s capacity and capability for quality improvement. Involves program leaders and other key staff to cement their personal commitment to quality. In a large organization, links the HIV quality program with the organization’s overall quality program.

8National Quality Center (NQC) Responsibilities of the Quality Management Committee Strategic planning Facilitating innovation and change Providing guidance and reassurance Allocating resources Establishing a common culture

9National Quality Center (NQC) Teams Outperform Individuals When  The task is complex  Creativity is needed  The path forward is unclear  More efficient use of resources is required  Fast learning is necessary  High commitment is desirable  The implementation of a plan requires the commitment of others  The task or process is cross-functional Peter Scholtes et al., The Team Handbook.

10National Quality Center (NQC) What Do Teams Need to Succeed? Clearly defined goals Well defined parameters Easily communicate within the organization Necessary knowledge and skills Accomplish tasks - how? Scholtes et al., The Team Handbook

11National Quality Center (NQC) Tips: Building the Team Include at least one member of the HIV quality committee on your project team Choose an experienced facilitator Include consumers of services on formal QI team/committee Take participant interests into account when assigning tasks or projects

12National Quality Center (NQC) Teams Work Best When Limited to 5 or 6 members Members can meet without logistical headaches Meetings are on target and succinct Meetings have a clear agenda Notes are kept and reviewed

13National Quality Center (NQC)

14National Quality Center (NQC) Overview of Quality Improvement Terminology and Principles

15National Quality Center (NQC) Two Dimensions of Quality Technical Quality Provider Perception of Quality of HIV Care Experiential Quality Consumer Perception of Quality of HIV Care Leonard Berry, Texas A&M University, IHI conference (2001)

16National Quality Center (NQC) Infrastructure enhances systematic implementation of improvement activities Infrastructure

17National Quality Center (NQC) What We Want to Avoid…….. Quality Management Program

18National Quality Center (NQC) Success is achieved through meeting the needs of those we serve. Is your facility ready?

19National Quality Center (NQC) Most problems are found in processes, not in people.

20National Quality Center (NQC) Do not reinvent the wheel – Learn from best practices.

21National Quality Center (NQC) Achieve continual improvement through small, incremental changes.

22National Quality Center (NQC) Actions are based upon accurate and measured data.

23National Quality Center (NQC) Infrastructure enhances systematic implementation of improvement activities.

24National Quality Center (NQC) Set Priorities and Communicate clearly

25National Quality Center (NQC) Building Quality into Daily Work Make QI part of job descriptions Incorporate quality concepts into new employee training Provide ongoing quality training to internal staff and to contractors Provide opportunities for internal staff and contractors to participate in QI projects Incorporate best practices into your service delivery

26National Quality Center (NQC) Consumer Involvement Framework

27National Quality Center (NQC) The Basics of Performance Measurement for Quality Improvement

28National Quality Center (NQC) Goals of Performance Measurement Monitor the quality of care provided Define possible causes of system problems Make changes necessary to ensure more patients receive better and appropriate care

29National Quality Center (NQC) What we’ll cover… Why measure? What to measure? When to measure? How to measure? Strategic planning for measurement

30National Quality Center (NQC) Reasons to Measure Separates what you think is happening from what really is happening Establishes a baseline: It’s ok to start out with low scores! Indicates whether changes actually lead to improvements Identifies slippage

31National Quality Center (NQC) Reasons to Measure (cont.) Ongoing / periodic monitoring identifies problems as they emerge Measurement allows for comparison across sites, programs, EMAs, TGAs and states The Ryan White HIV/AIDS Treatment Extension Act of 2009 mandates performance measurement The HIV/AIDS Bureau places strong emphasis on quality management

32National Quality Center (NQC) What is a Quality Indicator? A quality indicator assesses specific aspects of care and services that are linked to better health outcomes while being consistent with current standards and meeting the needs of clients.

33National Quality Center (NQC) Process Indicators Medical processes; i.e. how many CD4 tests were done in a day Case management processes; i.e. how many clients did you see today Clinic / agency / State / EMA / state processes Patient utilization of care underutilization overutilization misutilization Coordination of care processes; i.e. did a patient show up at their mental health appointment after clinic visit

34National Quality Center (NQC) Outcome Indicators Patient Health Status Intermediate outcomes like immune and virological status Survival Symptoms Disease progression Disability Subjective health status Hospital and ER visits Patient Satisfaction

35National Quality Center (NQC) What Makes a Good Indicator? Relevance  Does the indicator affect a lot of people or programs?  Does the indicator have an impact on the program or patients in your program? Measurability  Can the indicator realistically and efficiently be measured given finite resources?

36National Quality Center (NQC) What Makes a Good Indicator? (cont.) Accuracy  Is the indicator based on accepted guidelines or developed through formal group-decision making methods? Improvability  Can the performance rate associated with the indicator realistically be improved given the limitations of your services and population?

37National Quality Center (NQC) Define your Measurement Population Location: all sites, or only some? Gender: men, women, or both? Age: any limits? Client conditions: all HIV-infected clients, or only those with a specific diagnosis? Treatment status?

38National Quality Center (NQC) Create a Plan Decide on a sampling plan (sample size, eligible records, draw a random sample) Develop data collection tools and instructions Train data abstractors Run pilot test (adjust after a few records) Inform other staff of the measurement process Check for data accuracy Remain available for guidance Make a plan for display and distribution of data

39National Quality Center (NQC) Strategies Depend on Resources Data systems enhance capability  More indicators can be measured  Indicators can be measured more often  Entire populations can be measured  Outcome as well as process indicators can be measured  Alerts, custom reports help manage care Personnel resources  Person power for chart reviews, logs, other means of measurement is needed  Expertise in electronic / manual measurement

40National Quality Center (NQC) Indicator Definition Eligibility (patients over 18 years of age seen in the clinic in the last 12 months) Numerator (# of pts with prescribed PCP prophylactic therapy) Denominator (# of patients 18 years of older with CD4 counts < 200 cells/mm3)

41National Quality Center (NQC) Eligible Patients/Sample (pts seen in the clinic in the last 12 months) Denominator (pts with CD4 counts < 200) Numerator (pts with prescribed PCP prophylactic therapy)

42National Quality Center (NQC) Frequency You don’t need to measure everything all of the time (You can sample a short period of time and extrapolate the results) Balance the frequency of measurement against the cost in resources If limited resources, measure areas of concern more frequently, others less frequently Balance the frequency of measurement against usefulness in producing change Consider the audience. How will frequency best assist in setting priorities and generating change?

43National Quality Center (NQC) Questions for Data Follow-up What are the results for key indicators? What are the major findings based on the generated data reports and your data analysis?  What is the frequency of patients / programs not getting care?  What is the impact of not getting the care?  How does the performance compare with benchmark data?  What is the feasibility of improving the care?

44National Quality Center (NQC) Questions for Data Follow Up (Cont’d) How can you best share the data results with your key stakeholders (Part A/B QI committees, HIV providers, consumers, etc.)? How do you generate ownership among providers and consumers? How will you assist in initiating/implementing QI projects to address the data findings? Who will be responsible and what are the next steps? How do you publicize, celebrate and share results of QI projects recommended by consumers and/or staff that have lead to positive outcomes?

45National Quality Center (NQC) Making Changes That Work

46National Quality Center (NQC) Improvement is about learning  trial and error (scientific method)  improvements require change, however not all changes are an improvement Measure your progress  only data can tell you whether improvements are made  integrate measurement into the daily routine Improvements thru continuous cycles of changes  Plan-Do-Study-Act approach  changes are initiated on a small scale to test them before implementation Model for Improvement

47National Quality Center (NQC) What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement developed by Associates in Process Improvement

48National Quality Center (NQC) What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement developed by Associates in Process Improvement

49National Quality Center (NQC) What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement But how do we really know if it will work? developed by Associates in Process Improvement

50National Quality Center (NQC) Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data The PDSA cycle for learning and improvement

51National Quality Center (NQC) Why Test? Increase your confidence that the change will result in improvement in your organization Learn how to adapt the change to conditions in the local environment Minimize resistance when you move to implementation

52National Quality Center (NQC) How do tests lead to improvements? You learn something from each test. That knowledge gets incorporated into the next test. Over time, as you build knowledge and expertise, you design a change that will result in improvement.

53National Quality Center (NQC) Start Small and Build… Cycle 1A: Adapt new CM form and test with one of Joanne’s patients on Monday Cycle 1B: Revise tool and test with 3 case managers and document feedback Cycle 1C: Revise and test tool with all clients for one week Cycle 1E: Implement new tool and monitor the standards Introduce new CM Intake & Assessment Form Improve Access to HIV Primary Care

54National Quality Center (NQC) Tips for PDSA Cycles “What change could you implement by next Tuesday?” Use the “Rule of 1”:  1 facility  1 office  1 provider  1 patient

55National Quality Center (NQC) Questions?

56National Quality Center (NQC) NQC Quality Academy Additional Resources