1. Quality Improvement 101 and HRSA/HAB Expectations
Welcome to the NQC National TA Conference Call:
Quality Improvement 101 and HRSA/HAB Expectations
May 12, 2011

2. Presentation Overview
Quality Definitions
Key Principles of Quality Improvement
PDSA Cycle
HRSA/HAB Quality Expectations
QM Resources

3. to Quality Improvement
A Brief Introduction
to Quality Improvement
Kevin Garrett
National Quality Center
New York State AIDS Institute

4. 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)

5. Quality Improvement/Quality Assurance
What is the difference
between Quality Assurance and
Quality Improvement???
Quality Assurance (QA) = a broad spectrum of evaluation activities aimed at ensuring compliance with pre-established quality standards.
Quality Improvement (QI) = refers to activities aimed at improving performance/improving processes to enhance the quality of care and services.

6. ‘QI is not QA’ Motivation
Quality Assurance
Quality Improvement
Motivation
Measuring compliance with standards or agreed to commitments
Continuously improving processes to meet standards
Means
Inspection
Data analysis
Focus
Outliers
Processes
Systems
Responsibility
Few
All

7. Balance between Performance Measurement and QI Activities
Quality
Management Program

8. What We Want to Avoid……..
Quality
Management Program 8

9. Principles on the Quality Improvement Journey…

10. Success is achieved through meeting the needs of those we serve.

11. Most problems are found in processes, not in people.

12. Do not reinvent the wheel – Learn from best practices.

13. Achieve continual improvement through small, incremental changes.

14. Actions are based upon accurate and measured data.

15. Set Priorities and Communicate clearly

16. Infrastructure enhances systematic implementation of improvement activities.

17. How can we accelerate change and improvements in HIV programs?

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

19. Start Small and Build… Small- scale test Follow-up test Wide-scale
This diagram shows how the cycles build on each other. Eventually, you get to a wide-scale test of a change – trying a new screening tool in the entire clinic, for example. By the time you get to this point, when you’re involving all the staff – even those who are cranky and cynical – you’ve got a pretty good sense that the new tool will work. So, in a sense, you’ve taken the risk out of trying something new.
Small-
scale
test
Follow-up
test
Wide-scale
tests
Implementation 19

20. Start Small and Build… Cycle 1E: Implement new tool and monitor
Introduce new CM Intake/ Assessment Form
Improve Access to HIV Primary Care
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 20

21. 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?”
Toyota: 80 improvements per employee; US hospital: 0.5 improvement per employee
electronic interchange of improvement learning (IHI-Extranet; Kaiser Permanente-Learning Link; VHA Improvement Exchange)

22. Building Quality into Daily Work
Make quality management a part of contracts with providers
Make quality improvement a 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 quality improvement projects
Incorporate best practices into your service delivery

23. HRSA/HAB Quality Expectations
Tracy Matthews
Chief Clinical Advisor
HRSA/HAB
Division of Community Based Programs 23

24. HRSA/HAB Quality Expectations
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 24

25. HRSA/HAB Quality Expectations
“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 25

26. HRSA/HAB Quality Expectations
“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 measures for key clinical and service categories
Routine collection of performance measurement data for key care aspects
Analyze and share performance measurement data with program staff
Use of data to improve the organization’s performance on key services 26

27. HRSA/HAB Quality Expectations
“develop strategies for ensuring that such
services are consistent with the guidelines for
improvement in access to and quality of HIV
services…” which includes:
Establishment of quality improvement teams with cross-functional representation
Linking performance data results to quality improvement activities
Integration of changes into routine program activities 27

28. 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
A Quality Management Program should consist of a systematic process with identified leadership, accountability and dedicated resources and uses data and measureable outcomes  to determine progress toward relevant, evidence-based benchmarks.
Infrastructure
Performance Measurement
Quality Improvement 28

29. Key Characteristics of a Quality Management Program (cont.)
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 29

30. HAB Performance Measures
Six (6) sets of performance measures
clinical care (Groups 1, 2, 3)
medical case management
oral health
AIDS Drug Assistance Program
systems level
pediatrics
To assist grantees to “assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines”, HAB has developed detailed performance measures.
Based on input from key stakeholders, HAB has created & released six (6) sets of performance measures in the areas of clinical care, medical case management, oral health, AIDS Drug Assistance Program, systems level, and pediatrics.
The purpose of establishing performance measures is to:
Answer critical questions about the quality of care and services provided by the Ryan White community
Identify areas for improvement and make changes to improve care and services
Develop core clinical performance measures to be used by all grantees to measure clinical care 30

31. 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.
Can be used as defined or can be further modified by the grantee to meet that agency’s individual needs.
These measures can be used as defined or can be further modified by the grantee to meet that agency’s individual needs. Grantees are encouraged to select measures that are most important to their agencies and the populations they serve. The measures can be used by the Ryan White HIV/AIDS Program, either at the provider or system level.

32. HAB Clinical Performance Measures
Measures focus on clinical services provided to adults & adolescents
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.
The HAB HIV/AIDS Core Clinical Performance Measures for Adults & Adolescents are offered as a set of indicators for use in monitoring the quality of care provided. Grantees are encouraged to include the core clinical performance measures in their quality management plans. The clinical performance measures all are categorized into three groups.
Group 1 measures provide an excellent start and can serve as a foundation on which to build, especially if a clinical program has no performance measures.
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.

33. 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
The Medical Case Management Performance Measures target all clients, regardless of age and focus on two key issues: care plans and medical visits. Medical case management programs are encouraged to utilize the core clinical performance measures as appropriate.

34. 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
The Oral Health Performance Measures target all clients. The measures are intended for use by programs providing direct oral health services.

35. 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

36. HAB PM: System level Target all clients, regardless of age
Measures include:
Waiting time for initial access to outpatient/ambulatory medical care
HIV test results for PLWHA
Disease status at time of entry into care
Quality Management Program
System level performance
Intended to assess the system of care by an individual agency or by jurisdiction
Released 08/10

37. HAB PM: Pediatrics
Target clients, birth to youth – depending on the measure
Exposed and/or infected population
Measures include:
Lipid Screening
Medical Visit
MMR Vaccination
Neonatal Zidovudine Prophylaxis
PCP Prophylaxis for HIV Exposed Infants
PCP Prophylaxis for HIV Infected Children
Planning for Disclosure of HIV Status to Child
TB Screening
Adherence Assessment and Counseling
ARV Therapy
CD4 Value
Developmental Surveillance
Diagnostic Testing to Exclude HIV Infection in Exposed Infants
Health Care Transition Planning for HIV infected Youth
HIV Drug Resistance Testing before initiation of therapy
Intended for use by programs monitoring pediatrics and adolescents
Released 08/10

38. HAB Performance Measures
Grantees are not required to submit performance measurement data to HAB
FAQs developed as a companion guide and has been updated with the release of new measures
HAB performance measures are specific to the Ryan White HIV/AIDS Program

39. HAB Performance Measures: Next Steps
Performance measures related to:
viral load
Ensure performance measures are in alignment with National HIV/AIDS Strategy
Submit HIV performance measures for national endorsement 39

40. Any recommendations or suggestions for additional measures is welcome.
Any comments or feedback on the utilization of the measures is encouraged.
Any recommendations or suggestions for additional measures is welcome. 40

41. Key Quality Improvement Learning Opportunities
NQC Website
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)
Training on Coaching Basics (TCB)
Regional Trainings
Quality Link

42. NationalQualityCenter.org HIV measures Change ideas Best practices
Tools/resources
Literature
FAQ
“New to Quality Improvement” button
Each of these organizations has a web site, which we recommend you explore.
First, NQC’s web site is at nationalqualitycenter.org. This web site is designed to provide cutting-edge information on measures of quality in HIV care, ideas for changes that will result in improvement, best practices in providing HIV care and services, tools and other resources to strengthen quality management programs and quality improvement work, recent literature and answers to frequently asked questions. More than 170 different tools are currently posted on the website.
The NQC website contains links to the other sites mentioned in this Tutorial, so don’t worry if you don’t catch all the names.

43. References
ImprovementMethods provides information on improvement methods, strategies, and changes.
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.

44. National Quality Center (NQC)
NationalQualityCenter.org