1. Developing a Quality Management Plan
Sheila Boyle, ACRN, MS
Process Improvement Coordinator
AIDS Program, Albany Medical College
(518)

2. Background Academic, hospital-based, HIV clinic
Albany, NY
Academic, hospital-based, HIV clinic
RWCA Titles II, III, IV
Comprehensive services
Primary Care, Adherence, Case Management, Research, Nutrition, Mental Health, Substance Abuse, Dental
1200+ patients annually
Hispanic (12%), Black (37%), White (49%);
Male (64%), Female (36%), Transgender (0.5%);
MSM (29%), IDU (17%), Heterosexual (39%);
Medicaid (40%), Medicare (20%), ADAP (19%), Private (21%)

3. Elements of our Quality Management Plan
Mission Statement
Infrastructure
Annual Goals
Staff Involvement
Consumer Involvement
Evaluation and Updates

4. Developing a Quality Management Plan: Mission Statement
Ensure the highest quality of patient care
Focus on clinical outcomes

5. Developing a Quality Management Plan: Infrastructure
Core team
guides process
removes barriers
PI team
Multi-disciplinary
Monthly meetings
Adhoc committees as needed
Modified consensus
Ultimate decision-making authority lies with medical director
Hospital QIT
Core Team: PI coordinator, Clinic director, Operations manager
PI team: core team plus one provider and managers from nursing, client services, clerical, IS. Medical Director and Program administrator attend when feasible

6. Developing a Quality Management Plan: Annual Goals
60% with Annual Exam
90% with Visit in the last 4 Months
60% with PPD Reading
80% with Pap
70% with Secondary Prevention Intervention
Develop Mental Health Screening Tool and Diabetes Flow Sheet

7. Developing a Quality Management Plan: Staff Involvement
Monthly PI updates at full staff meetings
Quarterly PI updates and discussion with providers
Interactive full-staff PI meetings 2x/year

8. Developing a Quality Management Plan: Consumer Involvement
PI updates at each CAB (consumer advisory board) meeting
CAB members provide feedback and suggestions on PI projects
Several consumers on staff

9. Developing a Quality Management Plan: Evaluation and Updates
Monthly review of progress toward goals
Annual review of Quality Management Plan
Use of Addendum
Changes as needed

10. Developing Quality Management Plan: Albany Med’s Process
IHI collaborative
Formal documentation of QM plan
Changes to plan
Core team
Decision-making process
Staff involvement
CAB involvement
Addendum/Updates

11. Lessons Learned Evaluate the plan and revise prn Limit number of goals
Decision-making process
Structure
Limit number of goals
Know when to persevere
Keep frontline staff involved
Don’t give up if you think there are still some options
Keep plodding along vs. Knowing when goals just aren’t feasible