1. 1 Keep It Doable To Keep It Going Developing Your QM Infrastructure _______________________________ Nanette Brey Magnani, EdD, breymagnan@aol.com NQC Quality Consultant NQC National TA Call, April 12, 2007, 3 – 4 pm EST

2. 2 National Quality Center (NQC) Purpose of Presentation Purpose and components of a written Quality Management Plan with a focus on infrastructure development How to establish, implement, and sustain your Quality Management Program

3. 3 National Quality Center (NQC) Content of Presentation Purpose and components of QM Plan QM infrastructure components Grantee QM Programs  Near North Health Corporation (III)  Examples from other Title III/IV programs Grantee Contact Information Resources

4. 4 National Quality Center (NQC) Quality Management Plan Purpose  Identifies what needs to be accomplished (goals) and how to implement (workplan)  Clear indication of person(s) responsible  Sets the framework for holding the HIV program staff accountable for HIV quality management and performance improvement  Basis for self-evaluation for next cycle of improvement

5. 5 National Quality Center (NQC) Key Components of an Annual QM Plan Quality Statement QI Infrastructure - Focus of today Performance Measurement – 5/10 session Annual Quality Goals – integrated into 7/12 use of data Stakeholder Development – integrated into series Consumer Involvement – 9/13 session Evaluation Workplan

6. 6 National Quality Center (NQC) Quality Improvement Activities are Supported by a Quality Infrastructure QM Committee: Actors and Responsibilities

7. 7 National Quality Center (NQC) QM Infrastructure Components Quality Management (QM) Committee Quality Improvement Teams Involvement of Stakeholders

8. 8 National Quality Center (NQC) Basic Model HIV Program Staff Medical Director HIV Quality Committee QI Project Team

9. 9 National Quality Center (NQC) But we are only three people! Then, those same three people are the: Quality Committee, QI Project Team, and HIV Program Staff HIV Program Staff Quality Committee QI Project Team Medical Director/ HIV Physician It is what each of the groups/teams do that is important.

10. 10 National Quality Center (NQC) QM Committee/QI Project Team: Motivation and Effectiveness Depends On Finding the Right Mix Charge Membership Leadership

11. 11 National Quality Center (NQC) Quality Management Committee – The Charge Oversees the QM Program Develops annual QM Plan and evaluates past year’s efforts to provide input into the new plan Establishes priorities Sets QI goals Determines performance indicators Develops annual work plan/timeline for QM Plan Provides strategic thinking when developing annual plan

12. 12 National Quality Center (NQC) QM Committee cont’d Allocates and finds resources Establishes a QI culture (including staff education, stakeholder involvement) Facilitates innovation and change

13. 13 National Quality Center (NQC) QI Project Team – The Charge Makes process improvement recommendations to the HIV Quality Committee.  Reports to the QM Committee  Reviews indicator data and sets improvement goal  Collects additional data if needed

14. 14 National Quality Center (NQC) QI Project Team cont’d.  Develops a QI project plan  Select and test changes (Plan, Do, Study, Act  Spreads and sustains improvements  Presents findings (report, storyboard)

15. 15 National Quality Center (NQC) Involvement of Stakeholders Quality Committee Other department/program areas External agencies (Case Management, Title I, II) Consumers Consumer Advisory Board Board of Directors/sub- committee

16. 16 National Quality Center (NQC) Remember Margaret Meade’s famous quote: Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.

17. 17 National Quality Center (NQC) Here’s how several small, committed HIV program staff are building their program’s infrastructure to support the improvement of patient care.

18. 18 National Quality Center (NQC) QM Committee and QI Project Team Leadership Membership Meeting structure QM Plan QI Projects Physician Involvement

19. 19 National Quality Center (NQC) Making Quality Management an Integral Part of Your HIV program Small, Urban HIV Program Community Health Center

20. 20 National Quality Center (NQC) Near North Health Corporation, Inc. Chicago, Illinois Community health center with two sites; same clinical/HIV staff - 83 patients EIS Program Staff Team coordinator Adherence Counselor HIV Test Counselor Medical Director/Senior Leader of EIS HIV Quality Committee (EIS Team – 9 staff) Dir of QI EIS Coord Adh Couns HIV Test Couns Dir of Comprehensive Serv Medical Director/Sr. Leader of EIS SA counselor Nutritionist Data Analyst QI Project Team Data entry staff shared Across program areas

21. 21 National Quality Center (NQC) Near North Health Corporation cont’d. Leadership – The Medical Director attends monthly meetings; extensively involved. Day-to-day management of Committee – Dir of Quality Improvement for the health center; EIS Team Coordinator Membership – Three EIS Program staff; 6 additional health center staff join to form the HIV Quality Committee (EIS Team). Meeting structure – The EIS team meets on the 3 rd Tuesday of each month for approximately one hour.

22. 22 National Quality Center (NQC) Near North Health Corporation cont’d. QM Plan – updated annually; Annual data collection (HIVQUAL indicators/software) with monthly measurement. QI Projects - QM meetings are part of monthly EIS team meetings. E.g., sharing and discussing PDSAs Physician Involvement - The Medical Director is actively involved in the monthly meetings, is the Senior Leader of the EIS Program, and sees HIV patients.

23. 23 National Quality Center (NQC) Additional Grantee QM Programs Urban network, Title IV Large, multi-site urban community health center (can also resemble some Title IV programs) 2 Rural hospital program with multiple sites Small, urban community health center City health department program

24. 24 National Quality Center (NQC) Michigan Department of Community Health Title IV QM committee = Title IV Prog.Director Title IV Exec. Comm Prog. Med.Directors Agency Ex.Dir. QM staff Mich. Dept of Community Health Sub contractors

25. 25 National Quality Center (NQC) MDCH Title IV cont’d. Leadership – Subset of all 7 subcontracted agencies; physicians involved through participation on the QM Committee/Exec. Committee. Day-to-day management of Quality Committee – Title IV Program Director spends about 10 hours/month. Meeting structure – QM Committee meets quarterly; average 2 hours (longer if needed)

26. 26 National Quality Center (NQC) MDCH Title IV cont’d. QM Plan – MDCH responsible for QM Plan which incorporates all the subcontracted programs/agencies. Four of the seven programs and agencies have their own QM plans req by Title I, but will be used by Title IV for applicable indicators. QI Projects – Currently, each of the seven subcontracted programs/agencies are doing one QI Project, with one program doing two. Total: 8 Report QI Project progress at QM Committee meetings.

27. 27 National Quality Center (NQC) MDCH Title IV cont’d. Physician Involvement – Involved through their participation in the Executive Committee/HIV Quality Committee.

28. 28 National Quality Center (NQC) Large, Urban, Multi Site Community Health Center

29. 29 National Quality Center (NQC) Unity Health Care, Inc. Washington, DC (community health center, 1,500 HIV patients)

30. 30 National Quality Center (NQC) Unity Health Care, Inc cont’d. HIV QI Sub committee (Quality Committee) and Leadership. One team leader from each of the seven participating sites plus 1 NCM, HIV physician, and occasionally the HIV (Clinical) Service Director. At 5 of the sites, there is a site QI Committee which may have an added QI Project. Each of the 7 participating sites has at least one provider on its team. Day-to-day management of Quality Committee – Supervisor of HIV Nurse Case Managers and HIV Service Director (physician) coordinate HIV monthly provider meetings and HIV QI Sub Committee. Supervisor of HIV NCM spends at least 30-40% of time on QI: works with new staff; coordinates meetings; all planning for HIV QI. Meeting structure – HIV QI Sub Committee meets monthly for 2 hours; a new site is added yearly; sometimes includes training; issues related to systematizing change to make them a standard part of clinic practice; QI issue

31. 31 National Quality Center (NQC) Unity Health Care, Inc cont’d. QM Plan – The Supervisor of the NCM coordinates the development of the annual QM Plan at the HIV QI Sub Committee meetings. Updated annually in Nov and Dec. QI Projects – Each site does at least one project per year = 7 this year – either the same or different indicators. Physician Involvement – Provider is on each site based team; HIV physician tries to attend HIV QI Subcommittee meetings; HIV Service Director is a physician.

32. 32 National Quality Center (NQC) St. Mary’s Family Practice Grand Junction, CO with a second clinic in Durango – 178 patients HIV Quality Committee – Program staff: Program manager, Medical Case Manager, Medical Assistant, and MD when available. Day-to-day QM resp. – ultimate responsibility is with the Program Manager; Medical Case Manager does much of the HIVQUAL data entry; amount of time varies depending on work involved with a particular PDSA *There are four consistent people on HIV staff with one occasional employee and a data entry person one day a week. (This does not include physician time.)

33. 33 National Quality Center (NQC) St. Mary’s Family Practice cont’d. Meeting Structure - Meet monthly except if there are schedule conflicts. Included on the agenda as part of our staff meetings. Annual strategic planning meeting that meets in May or June – about 4-6 hours and in addition to Program staff and physician includes 3-4 consumers, physicians from Denver, Case management agencies. QM Plan – Key elements decided and updated at annual stategic planning meeting: QI goals, projects, etc.

34. 34 National Quality Center (NQC) St. Mary’s Family Practice cont’d. QI Projects – Three to four each year depending on the direction given the HIV program staff at the annual Strategic Planning. Physician Involvement - The most effective way we get physicians (from Denver, Durango) involved is at our annual strategic planning meeting. Close daily contact with HIV program Medical Director (at St. Mary’s) allows quick, easy access for questions, periodic reviews and progress.

35. 35 National Quality Center (NQC) Fletcher Allen Health Care Burlington, VT with 4 Rural Hospitals – 340 patients HIV Quality Committee – Same people, all the time. HIV physician and Nurse Practitioner at Fletcher Allen oversees QM and NP and SW in each clinic. Day-to-day QM resp. – responsibility is at each clinic. We spend an hour or two/month in addition to the meetings and focused time on projects. Meeting Structure – meet 4 times/year as the HIV Quality Committee for 3-4 hours; additionally Fletcher Allen (FA) physician and NP meet 3-4 times per year to discuss CQI.

36. 36 National Quality Center (NQC) Fletcher Allen Health Care cont’d QM Plan – Key parts of which are guided by our grant. QI Projects – Each clinic is responsible for its own QI project; some are quite small so maybe one QI Project. At FA about 3/year. Physician Involvement - HIV physician at Fletcher Allen oversees the Title III program’s QM Program; helps writes the grant; meets 3-4 times/year between quarterly meetings with regional hospital representatives.

37. 37 National Quality Center (NQC) 16th Street Community Health Center Milwaukee, WI – 113 patients HIV Quality Committee – Same people, all the time. CQI Coordinator, HIV Director, RNs, Social Workers, HIV Physician. Day-to-day QM resp. – CQI coordinator. Meeting Structure – Once/month for an hour (QM Committee)

38. 38 National Quality Center (NQC) 16th Street Community Health Center cont’d. QM Plan – Updated annually following submission of annual HIVQUAL data. QI Projects – approximately 3/year; about 1 hr/month/project; about 1 hr/month/project for data collection (measurement of tests of change) Physician Involvement - Physicians are included on emails, meetings, trainings, and seminars.

39. 39 National Quality Center (NQC) Denver Health and Hospital Authority Denver, CO Approx. 400 patients HIV Quality Committee/meeting structure - The entire clinic staff, though the Medical Advisor (lead physician) and nurse are really the leaders who spearhead efforts. The two leaders meet separately for about an hour on a monthly basis, and then present to the entire clinic at our monthly staff meetings. We have 11 staff members, though three are part-time physicians that add up to a total of only 0.8 FTE.

40. 40 National Quality Center (NQC) Denver Health and Hospital Authority cont’d. QI Projects - We generally do 1-2 QI projects/year. Physician Involvement - The lead physician presents the QM project to the other physicians at either our staff meetings or at separate provider meetings. In such a small clinic, it is relatively easy to get "buy-in" from the other physicians, and get them to contribute meaningfully.

41. 41 National Quality Center (NQC) Grantee Contact Information Near North Health Corporation, Chicago, IL Karen Iversen – kaiverse@nmh.orgkaiverse@nmh.org Michael Moore – micmoore@nmh.orgmicmoore@nmh.org Michigan Dept. of Community Health, Detroit Hollie Malamud-Price – malamudh@michigan.gov Unity Health Care, Inc., Washington, DC Sister Patricia Carroll – pcarroll@unityhealthcare.org St. Mary’s Family Practice, Grand Junction, CO Lucy Graham – Lucy.Graham@stmarygj.org

42. 42 National Quality Center (NQC) Grantee Contact Information cont’d. Fletcher Allen Hospital, Burlington, VT Deborah Kutzko – deborah.kutzko@vtmednet.orgdeborah.kutzko@vtmednet.org 16 th Street Community Health Center, Milwaukee, WI Maryam Tabrizi - maryam.tabrizi@sschc.orgmaryam.tabrizi@sschc.org Kathleen Donovan - kathleen.donovan@sschc.orgkathleen.donovan@sschc.org Denver Health and Hospital Authority, Denver, CO Josh Blum, MD - Joshua.Blum@dhha.orgJoshua.Blum@dhha.org

43. 43 National Quality Center (NQC) Resources RWCA All-Grantee Presentations, 8/06 and NQC Web Ex Presentations, 4/12/07 are on NQC web site. For Technical Assistance contact: National Quality Center, nationalqualitycenter.org National HIVQUAL Project through your Project Officer, www.hivqual.orgwww.hivqual.org

44. 44 National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY 10007-2919 888-NQC-QI-TA Info@NationalQualityCenter.org NationalQualityCenter.org