Funded by HRSA HIV/AIDS Bureau How to write and update a Quality Management Plan? Clemens Steinböck, MBA “How can you make this topic entertaining and keep everyone from falling asleep?” National Technical Assistance Call June 5 th, 2006

2National Quality Center (NQC) What are my options? Use pictures

3National Quality Center (NQC) What are my options? Use humor

4National Quality Center (NQC) What are my options? Use my kids

5National Quality Center (NQC) What are my options? or Use the audience…

6National Quality Center (NQC) Polling

7National Quality Center (NQC) 5. How would you define a Quality Management Plan? a)A workplan outlining annual QI activities, not describing the QM infrastructure b)A written document that outlines the Quality Management Program c)Same as Quality Management Program d)Represents the organizational structure of the formal HIV Quality Program

8National Quality Center (NQC) 6. Which statement about the Quality Management Plan is TRUE? a)A QI plan should not reference JCAHO and its framework for quality improvement b)A Title III/IV QM plan should only address Ryan White funding requirements for quality c)An up-to-date QM Plan is an expectation for Title III and Title IV grantees d)A complete QM Plan needs to have at least 15 pages or more

9National Quality Center (NQC) 7. Which of the following elements should be included in a Quality Management Plan? a)Quality statement b)Quality improvement infrastructure c)Performance measurement d)Annual quality goals e)Participation of stakeholders f)Evaluation g)All of the above h)None of the above

10National Quality Center (NQC) 8. Which of the following rules to write a QM Plan is NOT correct? a)If you have not touched your plan in the last 6 months, bring it to the next QM meeting b)80% planning, 20% writing (an old software programming rule) c)Do not reinvent the wheel, use an established framework to get started d)The ultimate measure of a good plan is that only the entire planning group agrees e)A perfect QM plan is probably written by the consultant (and nobody knows anything about it)

11National Quality Center (NQC) What we will cover: Quality Management Plan Quiz/Poll Definitions of Terms Elements of a Quality Management Plan 10 Rules by Clemens

12National Quality Center (NQC) Definitions of Terms Quality Management Program: The term ‘quality management program’ encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (e.g., committee structures with stakeholders, providers and consumer) and quality improvement related activities (performance measurement, QI project and QI training activities).

13National Quality Center (NQC) Definitions of Terms Quality Management Plan: A Quality Management Plan is a written document that outlines the grantee-wide HIV Quality Program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the Program.

14National Quality Center (NQC) TA Resource: Quality Management Program Assessment Tool Title-specific Organizational Assessment Tool of the HIV Quality Management Program Categories of assessment questions with detailed scoring instructions (score 0 – low; score 5 - high)

15National Quality Center (NQC) TA Resource: Quality Management Plan Checklist Checklist for the review of an HIV-specific Quality Management Plan Elements include:  Quality statement, Quality infrastructure, QM Plan implementation, Performance measurement, Annual quality goals, Participation of stakeholders, Evaluation, Capacity Building, Process to update QM Plan, Communication, Formatting

16National Quality Center (NQC) Elements of a Quality Management Plan Quality statement Quality improvement infrastructure Performance measurement Annual quality goals Participation of stakeholders Evaluation

17National Quality Center (NQC) Part 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?“

18National Quality Center (NQC) Part 1: Quality Statement Tips: Be brief Be visionary Include internal and external expectations Make references to Ryan White legislative requirements on quality management

19National Quality Center (NQC) Part 2: Quality Improvement Infrastructure How are we organized? Leadership Who is responsible for the grantee-wide quality improvement initiatives? Accountability Who are the major stakeholders? What are their expectations for the quality management program? Quality committee(s) structure Who serves on the internal and external quality committee(s)? Who chairs the HIV quality committee(s)? When will the quality committee meet to assess progress and plan future activities? How will QI activities be communicated? Resources What are the resources for the QM Program? Staffing?

20National Quality Center (NQC) Part 2: Quality Improvement Infrastructure Tips Not more than 3-5 pages (not every detail is needed) Avoid naming individuals (just job functions) List internal and external stakeholders List linkages

21National Quality Center (NQC) Part 3: Performance Measurement How will we assess progress? identify and quantify the critical aspects of care and services provided in your HIV program develop indicators and measure the progress of the QM Program

22National Quality Center (NQC) Part 3: Performance Measurement Tips include the process for reviewing and updating the indicators (who/when/how) include a portfolio of process, outcome and satisfaction measures include strategies how to report and disseminate results and findings

23National Quality Center (NQC) Part 4: Annual Quality Goals What are the priorities for the quality program? Quality goals are endpoints or conditions toward which quality program will direct its efforts and resources Develop a annual goals, the following three criteria can be helpful:  Frequency: How many patients/clients received and how many 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?

24National Quality Center (NQC) 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 thresholds at the beginning of the year for each goal

25National Quality Center (NQC) Part 5: Participation of Stakeholders How will providers, consumer and other stakeholders be involved in the QM Program? Engage internal and external stakeholders Communicate information about quality improvement activities Provide opportunities for learning about quality

26National Quality Center (NQC) Part 5: Participation of Stakeholders Tips List internal and external stakeholders and their functions/responsibilities List proposed training opportunities for staff and providers

27National Quality Center (NQC) Part 6: Evaluation How will we evaluate our overall performance as a program? Evaluate quality infrastructure effectiveness  Was the quality committee effective in its efforts to improve the quality of HIV care/services? Does the quality infrastructure require any changes? Evaluate QI activities  Were annual quality goals for quality improvement activities met? Did the implementation of the annual work plan go as planned? Performance measures  Were the measures appropriate to assess the clinical and non- clinical HIV care? Are the results in the expected range of performance?

28National Quality Center (NQC) Part 6: Evaluation Tip 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

29National Quality Center (NQC) The 10 QM Plan Rules: Rule 1 - Size does not matter. Rule 2 – Do not reinvent the wheel, use established frameworks to get started. Rules 3 – 80% planning, 20% writing (old software programming rule). Rule 4 – ‘Steal Shamelessly, Share Senselessly.’ Rule 6 – Be inclusive, even it takes longer to get your final QM plan. Rule 5 – A few visionary annual goals are better than plenty of useful ones.

30National Quality Center (NQC) The 10 QM Plan Rules: Rule 7 – If you have not touched your plan in the last 6 months, bring it to the next quality committee meeting. Rule 8 – A perfect QM plan is probably written by the external consultant (and nobody knows anything about it). Rule 9 – Perfect plans are only as good as its implementation. Rule 10 – Get Started.

31National Quality Center (NQC) Contact Information Clemens Steinbock National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY NQC-QI-TA