Quality Improvement 101 and HRSA/HAB Expectations Welcome to the NQC National TA Conference Call: Quality Improvement 101 and HRSA/HAB Expectations May 12, 2011

Presentation Overview Quality Definitions Key Principles of Quality Improvement PDSA Cycle HRSA/HAB Quality Expectations QM Resources

to Quality Improvement A Brief Introduction to Quality Improvement Kevin Garrett National Quality Center New York State AIDS Institute

IOM - Definition of Quality “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)

Quality Improvement/Quality Assurance What is the difference between Quality Assurance and Quality Improvement??? Quality Assurance (QA) = a broad spectrum of evaluation activities aimed at ensuring compliance with pre-established quality standards. Quality Improvement (QI) = refers to activities aimed at improving performance/improving processes to enhance the quality of care and services.

‘QI is not QA’ Motivation Quality Assurance Quality Improvement Motivation Measuring compliance with standards or agreed to commitments Continuously improving processes to meet standards Means Inspection Data analysis Focus Outliers Processes Systems Responsibility Few All

Balance between Performance Measurement and QI Activities Quality Management Program

What We Want to Avoid…….. Quality Management Program 8

Principles on the Quality Improvement Journey…

Success is achieved through meeting the needs of those we serve.

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.

Set Priorities and Communicate clearly

Infrastructure enhances systematic implementation of improvement activities.

How can we accelerate change and improvements in HIV programs?

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

Start Small and Build… Small- scale test Follow-up test Wide-scale This diagram shows how the cycles build on each other. Eventually, you get to a wide-scale test of a change – trying a new screening tool in the entire clinic, for example. By the time you get to this point, when you’re involving all the staff – even those who are cranky and cynical – you’ve got a pretty good sense that the new tool will work. So, in a sense, you’ve taken the risk out of trying something new. Small- scale test Follow-up test Wide-scale tests Implementation 19

Start Small and Build… Cycle 1E: Implement new tool and monitor Introduce new CM Intake/ Assessment Form Improve Access to HIV Primary Care Cycle 1A: Adapt new CM form and test with one of Mary’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 20

Tips for PDSA Cycles Formulate question and predict results Test first in ‘safe zones’, use volunteers Use shorter test cycles to accelerate rate of improvement Scale down size of test (# of patients, clinics, time) Collect just enough data, not perfect data Learn from others ‘Steal shamelessly, Share senselessly’ Just get started! “What can you test by next Tuesday?” Toyota: 80 improvements per employee; US hospital: 0.5 improvement per employee electronic interchange of improvement learning (IHI-Extranet; Kaiser Permanente-Learning Link; VHA Improvement Exchange)

Building Quality into Daily Work Make quality management a part of contracts with providers Make quality improvement a 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 quality improvement projects Incorporate best practices into your service delivery

HRSA/HAB Quality Expectations Tracy Matthews Chief Clinical Advisor HRSA/HAB Division of Community Based Programs TMatthews@hrsa.gov 23

HRSA/HAB Quality Expectations All RWTMA grantees are required to establish clinical quality management programs to: Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections; and Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services 24

HRSA/HAB Quality Expectations “RWTMA grantees are directed to establish clinical quality management programs..” which include: Development of a comprehensive clinical quality management infrastructure, including routine QM Meetings with cross-functional representation Description of QM Program in a quality plan, with a clear indication of responsibilities and responsible parties Inclusion and involvement of key stakeholders in your quality program Designated leaders for quality improvement and accountability 25

HRSA/HAB Quality Expectations “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…” which includes: Development and/or adaptation of quality measures for key clinical and service categories Routine collection of performance measurement data for key care aspects Analyze and share performance measurement data with program staff Use of data to improve the organization’s performance on key services 26

HRSA/HAB Quality Expectations “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV services…” which includes: Establishment of quality improvement teams with cross-functional representation Linking performance data results to quality improvement activities Integration of changes into routine program activities 27

Key Characteristics of a Quality Management Program Patient-centeredness is a fundamental focus of quality care and supports the 5 characteristics that follow. 1. A systematic process with identified leadership, accountability, and dedicated resources available to the program 2. Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks 3. Focus on linkages, efficiencies, and provider and client expectation in addressing outcome improvement A Quality Management Program should consist of a systematic process with identified leadership, accountability and dedicated resources and uses data and measureable outcomes  to determine progress toward relevant, evidence-based benchmarks. Infrastructure Performance Measurement Quality Improvement 28

Key Characteristics of a Quality Management Program (cont.) 4. A continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities 5. Ensure that data collected are fed back into the quality improvement process to assure that goals are accomplished and that they are concurrent with improved outcomes 29

HAB Performance Measures Six (6) sets of performance measures clinical care (Groups 1, 2, 3) medical case management oral health AIDS Drug Assistance Program systems level pediatrics http://hab.hrsa.gov/special/habmeasures.htm To assist grantees to “assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines”, HAB has developed detailed performance measures. Based on input from key stakeholders, HAB has created & released six (6) sets of performance measures in the areas of clinical care, medical case management, oral health, AIDS Drug Assistance Program, systems level, and pediatrics. The purpose of establishing performance measures is to: Answer critical questions about the quality of care and services provided by the Ryan White community Identify areas for improvement and make changes to improve care and services Develop core clinical performance measures to be used by all grantees to measure clinical care 30

HAB Performance Measures Grantees are encouraged to: track and trend data on these measures to monitor the quality of care provided. select measures that are most important to their agencies and the populations they serve. identify areas for improvement and to include these in their quality management plans. Can be used as defined or can be further modified by the grantee to meet that agency’s individual needs. These measures can be used as defined or can be further modified by the grantee to meet that agency’s individual needs. Grantees are encouraged to select measures that are most important to their agencies and the populations they serve. The measures can be used by the Ryan White HIV/AIDS Program, either at the provider or system level.

HAB Clinical Performance Measures Measures focus on clinical services provided to adults & adolescents Categorized into three groups: Group 1 measures provide an excellent start and can serve as a foundation on which to build. Group 2 measures are important measures for a robust clinical management program and should be seriously considered. Group 3 measures represent areas of care that are considered "best practice," but may lack written clinical guidelines or rely on data that are difficult to collect. The HAB HIV/AIDS Core Clinical Performance Measures for Adults & Adolescents are offered as a set of indicators for use in monitoring the quality of care provided. Grantees are encouraged to include the core clinical performance measures in their quality management plans. The clinical performance measures all are categorized into three groups. Group 1 measures provide an excellent start and can serve as a foundation on which to build, especially if a clinical program has no performance measures. Group 2 measures are important measures for a robust clinical management program and should be seriously considered. Group 3 measures represent areas of care that are considered "best practice," but may lack written clinical guidelines or rely on data that are difficult to collect.

HAB PM: Medical Case Management Targets all clients, regardless of age and focus on two key issues: Care plan Medical visits Medical case management programs are encouraged to utilize the core clinical performance measures as appropriate. Released 12/09 The Medical Case Management Performance Measures target all clients, regardless of age and focus on two key issues: care plans and medical visits. Medical case management programs are encouraged to utilize the core clinical performance measures as appropriate.

HAB PM: Oral Health Measures include: Dental & Medical History    Dental Treatment Plan    Oral Health Education    Periodontal Screening or Examination    Phase I Treatment Plan Completion The measures are intended for use by programs providing direct oral health services. Released 12/09 The Oral Health Performance Measures target all clients. The measures are intended for use by programs providing direct oral health services.

HAB PM: AIDS Drug Assistance Program Target all clients, regardless of age Measures include: Application Determination   Eligibility Recertification    Formulary    Inappropriate Antiretroviral Regimen Intended for use by the ADAP programs Released 12/09

HAB PM: System level Target all clients, regardless of age Measures include: Waiting time for initial access to outpatient/ambulatory medical care HIV test results for PLWHA Disease status at time of entry into care Quality Management Program System level performance Intended to assess the system of care by an individual agency or by jurisdiction Released 08/10

HAB PM: Pediatrics Target clients, birth to youth – depending on the measure Exposed and/or infected population Measures include: Lipid Screening Medical Visit MMR Vaccination Neonatal Zidovudine Prophylaxis PCP Prophylaxis for HIV Exposed Infants PCP Prophylaxis for HIV Infected Children Planning for Disclosure of HIV Status to Child TB Screening Adherence Assessment and Counseling ARV Therapy CD4 Value Developmental Surveillance Diagnostic Testing to Exclude HIV Infection in Exposed Infants Health Care Transition Planning for HIV infected Youth HIV Drug Resistance Testing before initiation of therapy Intended for use by programs monitoring pediatrics and adolescents Released 08/10

HAB Performance Measures Grantees are not required to submit performance measurement data to HAB FAQs developed as a companion guide and has been updated with the release of new measures http://hab.hrsa.gov/special/habmeasures.htm HAB performance measures are specific to the Ryan White HIV/AIDS Program

HAB Performance Measures: Next Steps Performance measures related to: viral load Ensure performance measures are in alignment with National HIV/AIDS Strategy Submit HIV performance measures for national endorsement 39

Any recommendations or suggestions for additional measures is welcome. Any comments or feedback on the utilization of the measures is encouraged. Any recommendations or suggestions for additional measures is welcome. HIVMeasures@hrsa.gov 40

Key Quality Improvement Learning Opportunities NQC Website www.NationalQualityCenter.org Publications Online Quality Academy-32 Tutorials (8 in Spanish!) Monthly TA Calls On-site TA for Ryan White grantees (NQC and HIVQUAL) Training of Trainers (TOT) Training for Quality Leaders (TQL) Training on Coaching Basics (TCB) Regional Trainings Quality Link

NationalQualityCenter.org HIV measures Change ideas Best practices Tools/resources Literature FAQ “New to Quality Improvement” button Each of these organizations has a web site, which we recommend you explore. First, NQC’s web site is at nationalqualitycenter.org. This web site is designed to provide cutting-edge information on measures of quality in HIV care, ideas for changes that will result in improvement, best practices in providing HIV care and services, tools and other resources to strengthen quality management programs and quality improvement work, recent literature and answers to frequently asked questions. More than 170 different tools are currently posted on the website. The NQC website contains links to the other sites mentioned in this Tutorial, so don’t worry if you don’t catch all the names.

References http://www.IHI.org/IHI/Improvement/ ImprovementMethods provides information on improvement methods, strategies, and changes. Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62. Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81. Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; The Improvement Guide. San Francisco, CA; Jossey-Bass, 1996. Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55.

National Quality Center (NQC) 212.417.4730 Info@NationalQualityCenter.org NationalQualityCenter.org