Back to Basics – QI 101 December 17, 2015 Presenter Kevin Garrett – NQC Senior Manager 1

QM Committee and Teams 2015 TOT Graduates 86,408 PLWA – reported in the 8 states At least 43,000 PLHIV – estimated TOTAL POTENTIAL IMPACT: IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States 2015 TOT Graduates

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. Let’s begin with the quality management committee. As we mentioned in our introduction, the quality management committee leads the HIV program’s quality improvement activities. Its job is to build the program’s capacity and capability for improvement. The committee should include leaders from different areas of your HIV program and their involvement in the committee’s work will help strengthen their personal commitment to quality as well. If your HIV program is part of a larger organization, you will want to coordinate your quality improvement work with that of your organization as a whole. The quality management committee helps to do this.

Responsibilities of the Quality Management Committee Strategic planning Facilitating innovation and change Providing guidance and reassurance Allocating resources Establishing a common culture The quality management committee has five broad responsibilities, beginning with strategic planning. They are responsible for establishing and driving the strategic goals of the organization’s quality management agenda. It is their job to facilitate innovation and drive quality management changes by providing guidance and reassurance to everyone in the organization. This means that they are responsible for allocating resources where needed, and they need to work towards establishing a common culture among the different departments. Let’s look at each in a little more detail.

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. More and more organizations as complex as your own are using teams to tackle important issues. Research has found that teams outperform individuals in many situations. For example, in situations that are complex or unclear where creative thinking is required, you can greatly benefit from using a team. Also, if the focus is on efficiency, or speed, then you may want to consider tackling the problem with a team as well. Most importantly, teams are invaluable when many people need to commit to the change or the situation crosses departmental boundaries.

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 Other than being clear on the stages, you can help your team by being efficient. Here are a few tips that will help all members feel that they are contributing and that meetings are an effective use of their time. Teams work best when they’re not too big. 5 or 6 members is best. The size of teams matters. Make sure your teams aren’t too large – 8 members is a maximum, but smaller is better. Teams also work best when members can meet without logistical headaches. They need a quiet place, chairs and a table, and time away from their work. Health care organizations aren’t set up for a lot of meetings, and good meeting space can be hard to find. Make the effort to find it, and help teams work without distraction as much as you can. Its important that meetings start on time, end on time, and proceed without interruption. Remember, everyone has a job to do so stay on target. Meetings should run according to a previously planned agenda. Meeting notes and next steps are distributed to participants. If you do not have a prepared agenda, take a few minutes at the beginning of the meeting and prepare one on the spot. The recorder takes notes on action items during the meeting and reviews action items at the end of the meeting. Copy and distribute as the meeting ends so all are clear on who is supposed to do what.

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 Teams not only need to be integrated into improvement projects, but also they need to be integrated into the organization’s overall goals and vision. So what do teams need? Teams must have clearly defined purposes and goals that serve the organization. Teams need clearly defined parameters within which to work. Teams need to be able to get information and share findings with their colleagues. Teams need to have people with the necessary knowledge and skills to accomplish their tasks. Teams need to know how they are going to accomplish their tasks.

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 Here are a few more things to think about when forming a team. Include at least one member of the HIV quality committee on your project team. Keeping everyone on track and working cooperatively is challenging, so choose an experienced facilitator. Its also a good idea to include a consumer on the team. Remember to take participant interests into account when assigning tasks or projects. You don’t want people to dread their team work experience or they may not perform as well as they could. Keep in mind that improvement teams, which are the vehicles of quality improvement activities, meld together the skills, experiences and insights of different staff.

Annual Quality Management Plan

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

Key Elements of a Quality Management Plan Quality statement Quality improvement infrastructure Performance measurement Annual quality goals Participation of stakeholders Evaluation Workplan/Implementation Plan

NQC QM Plan Checklist

Overview of Quality Improvement Terminology and Principles 86,408 PLWA – reported in the 8 states At least 43,000 PLHIV – estimated TOTAL POTENTIAL IMPACT: IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States

Infrastructure enhances systematic implementation of improvement activities

What We Want to Avoid…….. Quality Management Program 15

Success is achieved through meeting the needs of those we serve. Is your facility ready?

Most problems are found in processes, not in people

Do not reinvent the wheel – Learn from best practices

Achieve continual improvement through small, incremental changes.

Actions are based upon accurate and measured data.

Infrastructure enhances systematic implementation of improvement activities. Pixelbay: mhttps://pixabay.com/en/city-aerial-view-buildings-691644/

Set Priorities and Communicate clearly

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 Seek input from the folks that use your services

The Basics of Performance Measurement

50,000 feet View Performance measures express how well (or poorly) something or someone is doing There are 2 basic types of measures: outcome and process Measures themselves are the first step in improvement; you can’t improve if you don’t measure how you’re doing If you think performance measurement is new to you, think again Have you ever participated in athletics and were told you were good at something Did you ever tell your brother or sister that you get better grades than them You have been exposed to some form of measurement for a long time

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

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

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 clinical quality management

What Makes a Good Measure? 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? Clearly, the universe of things that can be measured is vast. How do we begin to select a manageable number of areas to track? There are four main criteria to use in selecting sound indicators. The first two are: Relevance. Are you looking at something that matters to your program? And measurability. Can you actually measure this aspect of care, given the resources you have?

What Makes a Good Measure? (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? The next two criteria are: Accuracy. How valid is this indicator? Does it really reflect current professional knowledge? Does it build on accepted guidelines for HIV care? If it deals with an aspect of care not yet covered by a guideline, has there been consensus by professionals and peers? And lastly, Improvability: the ultimate goal is to improve the quality of care. As you select indicators, focus first on those that will help you improve. If you answer "no" to any of these questions, the indicator—while still relevant to patient care—is probably either too difficult to measure or less than critical to patient care. On the other hand, if you answer "yes" to all of the questions, you have most likely found a viable indicator that will give you the most benefit for your measurement resources.

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

Outcome Indicators Patient Health Status Patient Satisfaction Intermediate outcomes like immune and virological status Survival Symptoms Disease progression Disability Subjective health status Hospital and ER visits Patient Satisfaction

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? To start, you need to define your eligibility criteria for the measurement population. The measurement population consists of those patients who are eligible for measurement based on pre-established criteria. Defining a population requires identifying both which records should be reviewed and which should not. The key point here is to select the focus of your data collection efforts. Consider the following criteria to define your measurement population: - Location: What facilities within the care system will be included? - Gender: Does the indicator apply exclusively to men or women, or to both? - Age: Are there particular age limits? - Patient condition: Is a confirmed diagnosis required, or simply symptoms or signs? Do certain conditions make the patient ineligible? - Active treatment status: How many visits are required for eligibility? Must the patient currently be in treatment? Must the treatment have occurred within a certain time frame? When you are finished addressing these questions, you will have a list of eligibility criteria.

Bertie says, “If you start talking about math again I’m never coming down!”

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)

What Picture Shows Better Performance Eligible Patients/Sample (patients over 18 years of age seen In the clinic in the last 12 months) Denominator (# of pts with prescribed PCP prophylactic therapy) Numerator (# of patients 18 years of older with CD4 counts < 200 cells/mm3)

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?

I have all this data, now what?

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?

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?

Use Data to Improve

Model for Improvement 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, developed by the Associates for Process Improvement

What are we trying to accomplish? Model for Improvement 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? Why this question is important … highly corelated with success of a team .. developed by Associates in Process Improvement

that a change is an improvement? Model for Improvement 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? What is the second question … how will we know? Why is this important …. developed by Associates in Process Improvement

What change can we make that will result in improvement? Model for Improvement 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? So what is the third question? The changes that you make should align with your aim and measures… Where do they come from ? IHI change packages… Have worked .. Peers developed by Associates in Process Improvement But how do we really know if it will work?

The PDSA cycle for learning and improvement Act Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) What changes are to be made? Next cycle? Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data Originally conceived by Walter Shewhart in 1930's, and later adopted by W. Edwards Deming

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 Basically, a PDSA cycle is a test. In a way, it’s like a high school biology experiment. You develop a theory (if we use an adherence screening tool with each client or patient, we’ll be able to help more patients adhere to treatment), and then run a small test to see if your theory is true. Testing out improvement ideas is a tremendous help to implementation. From tests, you can Know that your idea will work in your organization Fine-tune an idea to meet the specific situation in your program or clinic Show people that the idea can work, so they’ll be more likely to give it a try themselves.

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. The answer lies in the repetitive nature of the tests. You run one PDSA cycle, and then another that is a little more complex (based on what you learned from the first), and then another that is still more complex.

Start Small and Build… Introduce new CM Intake & Assessment Form Improve Access to HIV Primary Care 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 49

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 We’ve learned: Keep the first test small. Remember Dr. Smith and her 35-minute screening tool. Give yourself a chance to even to fail in this first test. Sometimes you learn the most from trying something that really doesn’t work. A common question to those starting their first PDSA cycle is: what change can you implement by next Tuesday? This question forces you to think small by reducing the sample size (‘just a few records’) and decreasing the implementation timetable (‘within a few days’) to a minimum. One way to help you and your colleagues “keep it small” is to remember the Rule of 1. Design the first test for one facility, one office, one provider or one patient. See what happens, act on that knowledge, and then scale-up the test.

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To hear the recorded TA Call, go to: https://meetny.webex.com/meetny/ldr.php?RCID=518 fac74d2bd2c9a623737375bbc6b0f For further questions, please contact: Kevin Garrett, LMSW kevin@nationalqualitycenter.org 212.417.4541