1. Q UALITY M ANAGEMENT P LANS Brazos Valley Council of Governments July 2010 1

2. T HE B IG P ICTURE : QM P LAN D IAGRAM 2

3. Q UALITY M ANAGEMENT P ROGRAM The term Quality Management Program encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (e.g., committee structures, roles for stakeholders, providers and consumers) and quality improvement related activities (performance measurement, quality improvement projects and quality training activities). Key Terms 3

4. Q UALITY M ANAGEMENT P LAN A quality management plan is a written document that outlines the HIV quality program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the program. Key Terms 4

5. R EQUIREMENTS FOR A Q UALITY M ANAGEMENT P ROGRAM 5

6. Q UALITY M ANAGEMENT S YSTEMS REQUIRE … The presence of a documented, ongoing quality improvement process (program description and plan of work) A quality management committee function that includes member roles and responsibilities and documented minutes of each meeting Significant participation by an M.D. in quality management functions Evidence of actions to improve quality of care and services, including improvements in accessibility and availability of services Data analysis in order to identify quality issues 6

7. Q UALITY M ANAGEMENT S YSTEMS REQUIRE … Satisfaction surveys, follow up on all identified issues identified in the surveys, and documentation of improvement of those issues The identification of outcomes and efforts at improving them Identification, monitoring and improvement of adverse outcomes Corrective action plans for identified quality issues Program oversight and evidence of management improvements, including revisions to program documentation, policies and procedures, committee actions and other quality initiatives An annual evaluation of the quality management program 7

8. QM P LAN C OMPONENTS Quality Statement (Purpose) Measurable objectives for the QM program QM Committee Description (member roles, meeting schedule, committee goals and activities) Activities for identifying quality issues and adverse outcomes Method for analyzing and correcting quality issues (e.g., PDSA model) Evaluating your QM program QM Work plan – a time table with steps needed to implement your QM program 8

9. Q UALITY S TATEMENT A brief mission statement describing the end goal of the HIV quality program to which all other activities are directed 9

10. QM P ROGRAM O BJECTIVES 10

11. QM P ROGRAM G OALS /O BJECTIVES What you want to accomplish in your QM Program The measures could be process or outcome oriented Process measures are actions that are taken. A process measure could include an assessment of the number of patients with a completed medication adherence screen, the number of client files reviewed, or the number of no-shows to medical appointments. Outcome measures are the results of care (e.g., the CD4 levels of patients on antiretroviral therapy) 11

12. QM C OMMITTEE M EMBERSHIP Diverse membership representing all areas of the agency The quality management process should include participation by representatives from agencies involved in the entire continuum of care, including: state and local governments; health, mental health, and social service providers; minority community- based agencies, community-based organizations, and persons with HIV infection. Additionally, these representatives may participate on the QM committee. A physician is a member and has a significant interface with the QM process; Documentation of member roles and responsibilities; 12

13. QM C OMMITTEE R EQUIREMENTS Meets at least quarterly; Documentation of the process used to identify quality issues with actions to analyze and correct them (e.g. Plan-Do-Study-Act); Documentation of meetings that include attendance, agenda, meeting summary, material/information reviewed, issues/concerns identified and action taken; and Documentation that shows QM Plan objectives are reviewed and evaluated at least quarterly. 13

14. I DENTIFYING Q UALITY I SSUES Performance Measurement Data Review 14

15. I DENTIFYING Q UALITY I SSUES What are some ways that you identify quality issues? Performance measurement and data review Feedback from staff and clients Client complaints Chart reviews Collection of client satisfaction information (via surveys, suggestion box, etc) Notification from a hospital or other provider of an adverse outcome Monitoring reports from BVCOG or DSHS 15

16. C LIENT S ATISFACTION S URVEY P ROCESS Details of how the survey is developed, administered and evaluated annually; Appropriately worded to elicit potential barriers to access, cultural competency, and quality (e.g. general satisfaction, client participation, perceived outcomes, continuity of care, effectiveness or result of service, timeliness of care, customer service/staff skills); and Documentation of how results are used in the quality improvement process. 16

17. A DOCUMENTED COMPLAINT PROCESS THAT INCLUDES : Effective resolution of issues; Tracking of trends; and Description of how results of complaint trends are used in the quality improvement process. 17

18. M ETHOD FOR ANALYZING AND CORRECTING QUALITY ISSUES (e.g., PDSA model) 18

19. E VALUATING YOUR QM PROGRAM 19

20. E VALUATION : H OW W ILL W E A SSESS THE Q UALITY M ANAGEMENT P ROGRAM S P ERFORMANCE ? Infrastructure QM Plan Elements: Evaluation QI activitiesPerformance measures Did we improve HIV care and services? Do we require further adjustment? Were goals met? How effectively? Did work plan go as planned? Were established milestones hit? Were stakeholders informed? Was training provided? Are results in the expected range? 20

21. T IPS FOR E VALUATION 21

22. W ORK P LAN Activities planned for the year to implement your program Includes topics, people assigned, tasks, timeframes, steps taken/steps planned, dates completed Should be an ongoing work plan that is updated regularly 22

23. R EFERENCES AND R ESOURCES National Quality Center, Quality Academy http://www.nationalqualitycenter.org/QualityAcademy/ http://www.nationalqualitycenter.org/QualityAcademy/ Texas Department of State Health Services, AA Review Tool http://www.dshs.state.tx.us/hivstd/fieldops/EvalTools.shtm http://www.dshs.state.tx.us/hivstd/fieldops/EvalTools.shtm Institute of Medicine, Crossing the Quality Chasm: The IOM Health Care Quality Initiative, http://www.iom.edu/CMS/8089.aspx http://www.iom.edu/CMS/8089.aspx 23

24. 24