1. Funded by HRSA HIV/AIDS Bureau January 14, 2010 Welcome to the NQC National TA Conference Call: Quality Management 101 and HRSA/HAB Expectations

2. Funded by HRSA HIV/AIDS Bureau Presentation Overview HAB’s Quality Expectations Definitions Key Principles of Quality Improvement The Model for Improvement- PDSA Cycle QM Resources

3. National Quality Center (NQC)3 HRSA/HAB Quality Expectations Tracy Matthews Chief Clinical Advisor HRSA/HAB Division of Community Based Programs TMatthews@hrsa.gov

4. National Quality Center (NQC)4 Ryan White HIV/AIDS Program Reauthorization in Oct 2009 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

5. National Quality Center (NQC)5 Ryan White HIV/AIDS Program “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

6. National Quality Center (NQC)6 Ryan White HIV/AIDS Program “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 indicators for key clinical and service categories  Routine performance measurement of key care aspects  Sharing of performance data with program staff  Use of data to improve the organization’s performance on key services

7. National Quality Center (NQC)7 Ryan White HIV/AIDS Program “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV services…” which includes:  Linking performance data results to quality improvement activities  Establishment of Quality improvement teams with cross-functional representation  Integration of changes into routine program activities

8. National Quality Center (NQC)8 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

9. National Quality Center (NQC)9 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 Key Characteristics of a Quality Management Program (cont.)

10. National Quality Center (NQC)10 HAB Performance Measures Four (4) sets of performance measures  clinical care,  medical case management,  oral health and  AIDS Drug Assistance Programs http://hab.hrsa.gov/special/habmeasures.htm

11. National Quality Center (NQC)11 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. Detail sheets outline specific information related to each measure. Can be used as defined or can be further modified by the grantee to meet that agency’s individual needs.

12. National Quality Center (NQC)12 HAB Clinical Performance Measures Measures focus on clinical services provided to adults & adolescents Offered as a set of indicators for use in monitoring the quality of care provided. 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.

13. National Quality Center (NQC)13 HAB Clinical Performance Measures: Group 1 Represents the 5 core clinical performance measures deemed critical for HIV programs to monitor. Indicators*:  ARV Therapy for Pregnant Women  CD4 T-cell Count  HAART  Medical Visits  PCP Prophylaxis *There is no hierarchy in importance within the Group Released 12/07

14. National Quality Center (NQC)14 HAB Clinical Performance Measures: Group 2 Group 2 measures that reflect important aspects of care that impact HIV-related morbidity & focus on treatment decisions that affect a sizable population Adherence Assessment & Counseling Cervical Cancer Screening Hepatitis B Vaccination Hepatitis C Screening *There is no hierarchy in importance within the Group Released 8/08 HIV Risk Counseling Lipid Screening Oral Exam Syphilis Screening TB Screening

15. National Quality Center (NQC)15 HAB Clinical Performance Measures: Group 3 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. Chlamydia Screening Gonorrhea Screening Hepatitis B Screening Hepatitis/HIV Alcohol Counseling Influenza Vaccination MAC Prophylaxis *There is no hierarchy in importance within the Group Released in Summer 2009 Mental Health Screen Pneumococcal Vaccination Substance Abuse Screen Tobacco Cessation Counseling Toxoplasma Screening

16. National Quality Center (NQC)16 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

17. National Quality Center (NQC)17 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

18. National Quality Center (NQC)18 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

19. National Quality Center (NQC)19 HAB Performance Measures Grantees are not required to submit performance measurement data to HAB FAQs developed as a companion guide and is updated with each release of measures and annually http://hab.hrsa.gov/special/habmeasures.htm

20. National Quality Center (NQC)20 HAB Performance Measures: Next Steps Performance measures related to:  Systems level  Pediatrics CAREWare Performance Measurement Module

21. National Quality Center (NQC)21 HAB Performance Measures: Next Steps Any comments or feedback on the utilization of the measures is encouraged. Any recommendations or suggestions for additional measures is welcome. HIVMeasures@hrsa.gov

22. National Quality Center (NQC)22 Questions? Thank you! Tracy Matthews Chief Clinical Advisor Division of Community Based Programs TMatthews@hrsa.gov

23. Funded by HRSA HIV/AIDS Bureau A Brief Into to Quality Management Meera Vohra Meera@NationalQualityCenter.org

24. National Quality Center (NQC)24

25. National Quality Center (NQC)25 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)

26. National Quality Center (NQC)26 Overall Goal The best care we know how to give, for every patient, at every site, every day.

27. National Quality Center (NQC)27 Quality Improvement What is the difference between Quality Assurance and Quality Improvement???

28. National Quality Center (NQC)28 ‘QI is not QA’ Quality AssuranceQuality Improvement MotivationMeasuring compliance with standards Continuously improving processes to meet standards MeansInspectionPrevention AttitudeRequired, defensiveChosen, proactive FocusOutliers: “bad apples” Individuals Processes Systems ScopeMedical providerPatient care ResponsibilityFewAll

29. National Quality Center (NQC)29 Balance between Performance Measurement and QI Activities Quality Management Program

30. National Quality Center (NQC)30 QM Program Infrastructure QM Committee Annual QM Plan Annual QM Workplan Performance Measures Performance Measurement System Quality Management Program

31. National Quality Center (NQC)31 What We Want to Avoid…….. Quality Management Program

32. National Quality Center (NQC)32 Principles on the Quality Improvement Journey…

33. National Quality Center (NQC)33 Success is achieved through meeting the needs of those we serve.

34. National Quality Center (NQC)34 Most problems are found in processes, not in people.

35. National Quality Center (NQC)35 Do not reinvent the wheel – Learn from best practices.

36. National Quality Center (NQC)36 Achieve continual improvement through small, incremental changes.

37. National Quality Center (NQC)37 Actions are based upon accurate and measured data.

38. National Quality Center (NQC)38 Infrastructure enhances systematic implementation of improvement activities.

39. National Quality Center (NQC)39 In a Journal of Quality Improvement article, 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot? 1.23 days 2.60 days 3.397 days 4.504 days Pop Quiz!!

40. National Quality Center (NQC)40 Survey of 92 Quality Improvement Projects in Journal of Quality Improvement 504 days from problem identification to completion of first pilot 397 days from first team meeting to the end of first cycle 75 days to describe current situation in flowchart 62 days for data collection if change was improvement Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11): 619-632

41. National Quality Center (NQC)41 How can we accelerate change and improvements in HIV programs?

42. National Quality Center (NQC)42 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? Model for Improvement

43. National Quality Center (NQC)43 Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data The PDSA cycle for learning and improvement

44. National Quality Center (NQC)44 Start Small and Build… Small- scale test Follow-up test Wide-scale tests Implementation

45. National Quality Center (NQC)45 Start Small and Build… 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 Introduce new CM Intake/ Assessment Form Improve Access to HIV Primary Care

46. National Quality Center (NQC)46 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?”

47. National Quality Center (NQC)47 Building Quality into Daily Work Make QM part of contracts with providers 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

48. National Quality Center (NQC)48 References http://www.IHI.org/IHI/Improvement/ ImprovementMethods provides information on improvement methods, strategies, and changes.http://www.IHI.org/IHI/Improvement/ 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.

49. National Quality Center (NQC)49 Quality Improvement Resources: Websites, Publications, Technical Assistance

50. National Quality Center (NQC)50 Key QI Learning Opportunities NQC Website www.NationalQualityCenter.orgwww.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) Regional Trainings Quality Link

51. National Quality Center (NQC)51 NationalQualityCenter.org HIV measures Change ideas Best practices Tools/resources Literature FAQ “New to Quality Improvement” button

52. National Quality Center (NQC)52 HAB QM TA Manual & FAQ’s

53. National Quality Center (NQC)53 Quality Improvement Publications

54. National Quality Center (NQC)54 Publications

55. National Quality Center (NQC)55 QI Training Publications

56. National Quality Center (NQC)56 New Publications

57. National Quality Center (NQC)57 QM Program Assessment Tools & QM Plan Checklist

58. Funded by HRSA HIV/AIDS Bureau National Quality Center (NQC) 212.417.4730Info@NationalQualityCenter.orgNationalQualityCenter.org