Developing a Quality Management Plan Sheila Boyle, ACRN, MS Process Improvement Coordinator AIDS Program, Albany Medical College (518) 262-4025 BoyleS@mail.amc.edu

Background Academic, hospital-based, HIV clinic Albany, NY Academic, hospital-based, HIV clinic RWCA Titles II, III, IV Comprehensive services Primary Care, Adherence, Case Management, Research, Nutrition, Mental Health, Substance Abuse, Dental 1200+ patients annually Hispanic (12%), Black (37%), White (49%); Male (64%), Female (36%), Transgender (0.5%); MSM (29%), IDU (17%), Heterosexual (39%); Medicaid (40%), Medicare (20%), ADAP (19%), Private (21%)

Elements of our Quality Management Plan Mission Statement Infrastructure Annual Goals Staff Involvement Consumer Involvement Evaluation and Updates

Developing a Quality Management Plan: Mission Statement Ensure the highest quality of patient care Focus on clinical outcomes

Developing a Quality Management Plan: Infrastructure Core team guides process removes barriers PI team Multi-disciplinary Monthly meetings Adhoc committees as needed Modified consensus Ultimate decision-making authority lies with medical director Hospital QIT Core Team: PI coordinator, Clinic director, Operations manager PI team: core team plus one provider and managers from nursing, client services, clerical, IS. Medical Director and Program administrator attend when feasible

Developing a Quality Management Plan: Annual Goals 60% with Annual Exam 90% with Visit in the last 4 Months 60% with PPD Reading 80% with Pap 70% with Secondary Prevention Intervention Develop Mental Health Screening Tool and Diabetes Flow Sheet

Developing a Quality Management Plan: Staff Involvement Monthly PI updates at full staff meetings Quarterly PI updates and discussion with providers Interactive full-staff PI meetings 2x/year

Developing a Quality Management Plan: Consumer Involvement PI updates at each CAB (consumer advisory board) meeting CAB members provide feedback and suggestions on PI projects Several consumers on staff

Developing a Quality Management Plan: Evaluation and Updates Monthly review of progress toward goals Annual review of Quality Management Plan Use of Addendum Changes as needed

Developing Quality Management Plan: Albany Med’s Process IHI collaborative Formal documentation of QM plan Changes to plan Core team Decision-making process Staff involvement CAB involvement Addendum/Updates

Lessons Learned Evaluate the plan and revise prn Limit number of goals Decision-making process Structure Limit number of goals Know when to persevere Keep frontline staff involved Don’t give up if you think there are still some options Keep plodding along vs. Knowing when goals just aren’t feasible