1. National TA Call: Gaining Agency & Subcontractor Buy-in for Quality Management Thursday, October 17, 2013; 3-4:30pm EST Jane Caruso, NQC Consultant and Facilitator Dan Belanger, Director of NYS AIDS Institute Quality Program Terry Brey, Director of Part A Program Kansas City Hollie Malamud-Price, NQC Consultant

2. 2 Learning Objectives Understand the need to engage your agency and subcontractors in your quality management program Learn strategies to generate buy-in and develop a culture of quality with your agency and subcontractors Learn successful strategies from peers of different Ryan White Parts

3. 3 Housekeeping Notes Feel free to share your questions with the presenters and your peers in the chat room function throughout the webinar. We have 15 minutes for Q&A at the end of the call – have your questions and comments ready! Please don’t put us on hold. Your “Hold” music will be heard by all participants! Use #6 to unmute yourself during the live Q&A opportunities.

4. 4 Agenda ―Welcome and topic introduction! ―Experiences From the Field ― Q&A Session / Discussion / Experiences from the Audience Dan Belanger, Part B Terry Bray, Part AHollie Malamud-Price, Part D

5. 5 A Few General Motivation Tips That work across all Parts! Use specific contractual language Share/explain the federal mandates, NHAS, Executive Order Start small and simple with achievable expectations Build capacity and provide training Encourage agencies to engage all disciplines Understand that their INPUT to a project is important…seek it! Allow QI activities to become part of routine work Feedback and positive reinforcement are critical Praise every step toward improvement – out loud and in front of others Try working ACROSS subcontractors as well as WITH subcontractors Share success strategies and stories Encourage innovation and celebrate achievements

6. 6 Gaining Agency and Subcontractor Buy-in for Quality Management: Examples from the New York State HIV Quality of Care Program Dan Belanger Director, NYS HIV QOC Program AIDS Institute 6 The Part B Perspective

7. 7 NYS Quality of Care Program Infrastructure 7

8. 8 HIV Clinical Quality of Care Advisory Committee 8

9. 9 HIV Quality of Care Clinical Advisory Committee  Engagement of providers, QI experts and consumers across the state  Advises on development, implementation and refinement of the NYS HIV QM program  Building partnerships and trust since they are part of the process 9

10. 10 Consumer Advisory Committee 10

11. 11 Consumer Advisory Committees  Address topics to improve the quality of HIV care in NYS  CAC - comprised of adult consumers across NYS; provider representation from the Clinical Advisory Committee (meet quarterly)  YACAC - comprised of adolescent consumers across NYS (meet twice a year) 11

12. 12 Quality of Care Workgroup

13. 13 Internal Quality of Care Workgroup Meets monthly to facilitate communication about the Quality of Care Program and continuous quality improvement within the AIDS Institute To coordinate quality of care review activities within the AIDS Institute To maintain consistency in standards of care, presentation of data and improvement strategies throughout the HIV Continuum of Care 13

14. 14 NYS Quality of Care Program Engagement of Providers 14

15. 15 New York State Quality of Care Program Standards 15

16. 16 New York State Quality of Care Program Standards Clearly written quality standards that are applicable to all HIV programs in NYS, regardless of caseload, location or service delivery model  Includes the following domains: Infrastructure, Performance Measurement, Improvement activity, Staff Involvement, and Consumer Involvement Standards include descriptions for each standard to explain their applicability in HIV programs  Use of ‘simple’ language Same standards are incorporated in all contracts, including Medicaid agreements  Standardization of expectations across programs 16

17. 17 Annual Performance Measurement Review 17

18. 18 Annual Performance Measurement Review 184 HIV programs in NYS (beyond Part B funding) annually self-report key HIVQUAL indicators based on indicators that are developed with input from the Quality Advisory and Consumer Advisory Committees Programs use eHIVQUAL, an online application developed by the NYS to report their data; reports are validated by external agency  Data reports are instantaneously available in the application  Benchmarking reports are made available Providers are expected to use the results of the review to perform quality improvement activities as needed  Each program needs to submit follow-up activities 18

19. 19 Organizational Assessments Domains Quality Management Workforce engagement Measurement, Analysis and Use of Data QI Initiatives Consumer Involvement QI Program Evaluation Achievement of Outcomes 19

20. 20 Annual Organizational Assessments Based on the AIDS Institute quality program standards, organizational assessment tools have been developed Each of the 184 HIV programs in NYS is visited by a QOC staff/consultant to conduct an on-site Organizational Assessment to determine a sustainable QM infrastructure is in place; these activities are in addition to ongoing contract monitoring visits and performance data reviews Detailed findings and next steps are shared with CEO, medical director and program staff Findings from these assessments are discussed with contract managers for follow-up and detailed discussion about technical assistance needs If necessary, programs are offered technical assistance by QI expert 20

21. 21 Community Health Center Quality Learning Network HIV Viral Load Suppression QI Project Improve the VL Suppression rate by 10% across 7 community health centers by 12/31/12 Psycho-Social Support Retention ARV Adherence Clinic system/processes Clarity of purpose-goals, roles, responsibilities Clinic QM infrastructure Clinic environment Staff communication Clinic flow Treatment education Health literacy Health insurance Self efficacy consumer involvement Housing Substance Use Mental Health Case management/ SW Support Patient support network Appointments Transportation Continuity of care Staff attitude Staff/patient communication 21

22. 22 Technical Assistance (TA) and Coaching On-site technical assistance by QI expert based on agreed TA objectives Technical Assistance Monthly Reports to share progress with stakeholders Monthly QI workshops based on identified needs (QI 101 and more advanced topics) Peer learning opportunities between HIV programs Tracking of TA offerings by HIV program 22

23. 23 Primary Outcome Primary Drivers Increase the viral load suppression rate by 10% across clinics over a 10 month period Retention Psycho- Social Support ARV Adherence Substance Use Mental Health Appointments Transportation Continuity of care Treatment Education Health Literacy Health Insurance Housing Secondary Drivers

24. 24 Learning Networks Learning Networks, modeled after the IHI Breakthrough Series, combine ongoing on- site consultation with structured one-day/half-day group meetings that focus on quality management Provide a forum for peer learning which enables teams to exchange ideas through the network’s activities  Joint QI projects within network  Sharing of successes/challenges Learning networks currently underway include  3 HHC Networks, Substance Use Network, Adolescent Network, Upstate Network, Part C/D Network  harm reduction services, food and nutrition, treatment adherence support, mental health, case management and medical case management 24

25. 25 *A snorkel was performed at the HHC Learning Network to elicit creative ideas on how to improve the viral load suppression rate at HIV clinics. *Top five ideas were identified. Participants met in groups using DeBono’s six hats to discuss a plan to test these ideas. *Results were shared with the CHCLN providers participating in the Viral Load Suppression Project.

26. 26 Suppression Status Post-Intervention Viral Load Test(s) since 1/1/2013 Intervention Spread since 1/1/2013 Second Wave Eligible Patients (excludes patients included in First Wave) # of Unsuppressed patients eligible for the VLS QI Intervention # of Unsuppressed Patients Who Received a VLS QI Intervention in 2013 # of Patients Who Received a VL Test After Receiving the QI Intervention in 2013 # of Patients Suppressed As of: First VL Test After Receiving QI Intervention Most Recent VL Test in 2013

27. 27 Number of Clinics Submitting Monthly Reports

28. 28 Site – Cohort 1 patients # whose most recent VL during the Jan-March period is >200 #initiated with QI intervention as of 4/1/2012 # with a successful intervention # who received a post-initiation viral load test # who are suppressed Ryan – 17 patients WMY – 17 patients CHN – 117 patients 28

29. 29 June 8, 2012 Face-to-face Meeting: Test of Change Reporting Providers interview each other one-on-one on their PDSA cycles Each provider reports back to the larger group on the other provider’s project Providers reported learning more about specific intervention and experiences of other provider QI activities Providers reported that this exercise helped them to think through challenges. opportunities within their own viral load suppression QI activities

30. 30 Changes Tested by Site

31. 31 Annual Awards Ceremony 31

32. 32 Annual Quality of Care Awards Annual NYS QOC Program Awards in the following categories:  Excellence in Quality Performance  Senior Leadership on Quality Improvement  Achievement in Quality Improvement NYSDOH  Consumer Involvement In Quality Improvement Nomination/Application process with review by the Internal Workgroup 32

33. 33 Thank you! Questions? 33

34. 34 Engaging our Subcontractors in the Quality Improvement Effort How Do We Do It? The Part D Perspective Hollie Malamud-Price

35. 35 External Versus Internal Motivation External Motivation: In order to receive your funding from the Part D Network, you must comply with the QM Plan and perform QI activities Internal Motivation: Improvement of services Providing better care/experience for our consumers Improvement of process Building of relationships

36. 36 Get to Know Your Subcontractors Questions to Ask: Who are they? What do they care about? How do you relate to them? Engage as early as possible Listen with open ears Principals of Engagement

37. 37 Communicate, communicate, and communicate some more Use carrots, as much as possible, versus sticks Create common interests Principals of Engagement

38. 38 Engagement and commitment best achieved through a formal contract Contracts should include deliverables Deliverables may be tied to funding Engagement and Accountability

39. 39 Engagement Challenges The One “S” and Four “T’s” Silo Turf Time Trust Turnover

40. 40 Different providers Different services Multiple RW and other funding streams per provider All responsible for quality Challenges with Engagement In a Part D Network

41. 41 Engagement in Part D Networks If possible, find common areas for QI across agencies and funders Choose QI projects that meet agency and funders needs Ideally QI can also benefit the network, i.e.: referral, coordination, and retention

42. 42 Start small Choose a project which has a very good chance of success Provide supportive and positive TA along the way Praise every step in the right direction, avoid being judgmental or punitive or critical. If you are requiring periodic data reports, ALWAYS provide feedback on those reports….so they know that you are watching and that you care! How To Make The Move

43. 43 Step One  Agency gathers multidisciplinary QI Team (medical, SS & CM, data, consumer, QI)  Team creates a draft Transition Tool that can document that the critical pieces of transitioning education have been discussed with the patient (Steal shamelessly!) Example: Transition Planning for Adolescents

44. 44 Step Two  Pilot test with a few youth  Amend or modify tool as needed  Bring back to the QI Team  Finalize tool  Terrific! We’re doing great ! Example (continued)

45. 45 Example (continued) Step Three  Train all agency staff involved in its use  Discuss implementation timeline  Discuss documentation  Discuss goals and expectations  Great progress, almost there! Woohoo!

46. 46 Step Four Place tool in all adolescent charts/EMR records Implement use of tool Document use in database Thanks Data Manager, for creating the great tickler sheet, the extra database field and for entering our work into your database! You’re awesome! Example (continued)

47. 47 Step Five  Reconvene agency QI Team and include Grantee  Review first month’s efforts  Collect feedback from staff and any anecdotal feedback from patients  Ask Data Manager for basic numbers of tools completed and ask if any more detailed analysis could be conducted as more data are acquired.  Celebrate internally and share externally! Example (continued)

48. 48 Plan for Further Improvement and Sustainability Document, document, document!  Give credit everywhere it is due  Communicate the success to other subcontractors and to HRSA PO  Publish…..Post…..Present wherever possible  Continually collect and trend data  USE MOMENTUM TO CRAFT A NEW PROJECT!!!

49. 49 THANK YOU! Questions?

50. 50 Kansas City Transitional Grant Area Kansas City, Missouri Health Department Part A Grantee 11 Counties in Missouri, 4 Counties in Kansas HIV/AIDS population- 3,000 8 direct service providers The Part A Perspective Terry Bray

51. 51 Quality Advisory Committee Direct Service Providers Consumers State Health Department Collaborative Brainstorming!

52. 52 Quality Advisory Committee Performance Indicators Statewide Client Level Database Report to Planning Council

53. 53 Contractual Obligations QM Plan Client Satisfaction Survey Quality Improvement Project Storyboard

54. 54 Storyboards

55. 55 Contractual Obligations Quarterly reporting  Clients served  Client Demographics  Performance Indicators  Narrative

56. 56 Contractual Obligations QI training annually  Provided by Grantee  2 NQC Quality Academy Tutorials  Technical Assistance as needed

57. 57 Other QI Activities Multi-disciplinary teams One on One database training of new staff IN+Care Campaign Regional QI Workgroup HAB/NQC HIV Cross-Part Care Continuum Collaborative

58. 58 Thank you! Questions?

59. 59 Gaining Agency & Subcontractor Buy-in for Quality Management Do you have an additional strategies to increase buy-in for quality management among your subcontractors that you can share with the group? You can press #6 to unmute yourself! Or use the chat room to share your idea or ask a question to the panelists or the whole group

60. National Quality Center Kevin: kfg01@health.state.ny.us Jane: janecaruso@comcast.net Panelists Terry: terry.bray@kcmo.org Dan: drb08@health.state.ny.us Hollie: holliehivqual@gmail.com kfg01@health.state.ny.usjanecaruso@comcast.netterry.bray@kcmo.orgdrb08@health.state.ny.usholliehivqual@gmail.com