1. Nanette Brey Magnani and Susan Weigl
NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management Plans
April17, 2008
Nanette Brey Magnani and Susan Weigl
NYSDOH AIDS Institute

2. Learning Objectives
Understand the importance and role of a QM Plan to support ongoing QI activities
Understand key elements of a useful written QM Plan
Create a draft of a QM Plan update your own QM Plan
Know where to access resources to help you make your QM Plan a working and helpful, guiding document

3. Agenda 9:00 Welcome. Introductions Review agenda and materials.
9:15 Interactive Presentation: A Guide for Developing
Your QM Plans.
Individual/dyad exercise: After each component of a
QM Plan is presented, participants review examples
and highlight aspects of examples that are relevant to them.
11:00 Cut and paste highlighted parts into a draft QM Plan.
11:30 Large group sharing and next steps.
11:50 Feedback and evaluation.
12:00 Adjourn.

4. Infrastructure enhances systematic implementation of improvement activities

5. Quality Management Plan
Purpose
Provides direction of what needs to be accomplished (goals) and how it will be accomplished (action plan) and by whom
Sets the framework for holding the HIV program and providers accountable for the quality of patient care
Basis for self-evaluation for next cycle of improvement

6. Strategic QM Plan (3-5 yrs)
Grantee-wide Vision
Strategic QM Plan (3-5 yrs)
QM Plan
Annual Goals
Action Plan
Implementation
Annual Evaluation

7. Format and Components of a QM Plan
Section I: Description – Relatively unchanged from year to year
Quality statement
Infrastructure
Performance measurement
Annual quality goals
Stakeholder participation and development
Evaluation

8. QM Plan format and components contd.
Section II: Annual QI Action Plan– Changes from year to year
Presentation of data and results
Annual Improvement Goals/Objectives
QI Projects
Activity Timeline

9. How is the QM Plan written?
Decide on and systematize your approach to developing/updating your QM Plan
An annual planning meeting
A series of shorter meetings that could include piggybacking/using existing QM committee meetings
Getting input (for stakeholders who can’t attend meetings due to time, distance, etc.)

10. (Title of Program) Quality Management Plan
Section 1: Description of ____ HIV Quality Management Program

11. I.1. Quality Statement What do we want to be?
Brief purpose/mission statement describing the end goal of the HIV quality program to which all other activities are directed
Assume an ideal world and ask yourselves, "What do we want to be for our patients and our community?”

12. I.2. Quality Improvement Infrastructure
How are we organized?
Leadership
Who is responsible for the program-wide quality management initiatives?
Accountability
Who reports to whom re quality; what different committees/groups/meetings have a role in quality and how do they related to each other
Quality Committee(s) Structure
Members? Chairs? Roles? Frequency of meetings? Agendas?
Communication
Resources
Resources for the QM program? Staffing?

13. HIV Quality Management Committee
An HIV QM Committee oversees the quality management program. The plan usually addresses the following:
Committee composition
Frequency and schedule for meetings
Plan for recording agendas, minutes, and other documentation
Plan for consumer input

14. Description of QM Committee Responsibilities
Selects an improvement process model such as HIVQUAL model and use of PDSAs
Sets QI priorities
Recommends new policies or changes in current policy to promote quality care
Develops, monitors, and evaluates overall QM Program, QM Plan and Action Plan, and QI Projects.
Provides in put on quality perspective in other planning activities (strategic planning, program development, grants)

15. QM Committee resp. contd
Monitors performance measures on applicable PHS standards and on non-clinical standards related to access, linkages, services in support of clinical treatment, and/or other case management performance.
Designs new processes, systems and procedures consistent with CQI principles and with the results of QI Projects.
Develops a staff development plan to educate staff in quality principles and methods.
Maintains internal and external accountability for quality management.

16. Quality Improvement Teams
A QI Project Team is charged to make process improvement recommendations in the delivery of care to the HIV QM Committee.
Responsibilities:
Set improvement goals/objectives
Plan, test and measure changes
Provide progress reports to QM Committee
Manage spread of more successful change strategies
Evaluate effort

17. Quality Management Organizational Chart
Organization diagram/chart depicts:
Relationships: reporting, supervisory
Internal and external linkages
It helps to see it visually and oftentimes reveals more groups and individuals that have a role or need to be involved in some way. Also, helps to expand understanding of QM Program.

18. Waterbury Hospital Accountability Diagram
Internal Communication
WHICH QM Committee
HIV Care Team
Consumer Advisory
Group
Ryan White
Program Director

19. Plan for Communication
Internal communication (Monthly):
The QI program’s progress is on the agenda of the monthly HIV care team and the department of medicine’s monthly meeting. Two consumers are part of the HIV care team. The QI coordinator reports to the HIV care Team on the monthly progress re implementation of the QI work plan, sharing of data on QI projects, and the formation of subcommittees, as needed, during this meeting. The Program director and the CAG representative are present during the HIV care Team meeting.

20. Hospital Accountability Diagram
External Communication (annually)
WHICH QI Committee
Waterbury Hosp
QM Committee
-HRSA
-RW Part A office
Ryan White
Program Director
Waterbury Hosp
Executive
Management Team
Dept of Medicine
Director

21. I.3. Performance Measurement
How will we assess progress?
Identify what’s important (critical aspects of care and services provided)
Develop ways to measure what’s important
Include process, outcome and satisfaction measures

22. I.4. Setting Annual Quality Goals
How are the annual goals determined?
What group/staff?
What data is used?
What criteria?
How often?

23. I.5. Stakeholder Participation and Development
How will staff, providers, consumers and other stakeholders be involved in the QM program?
Who are they and how can they be involved in the QM Program (internal to the QM Program and external to it)
What information do they need and when
Provide opportunities for learning about quality improvement

24. I.6: Evaluation How will we evaluate our overall performance as a program?
Infrastructure
QI activities
Performance Measures
Did the QM Committee meet and oversee the QM program effectively?
Did QI Project Teams meet their goals? Were the right staff on the teams?
To what extent were consumers involved in the QM Program?
Was the action plan realistic and reflective of the work of the QM Committee, QI Project Teams, & QM Program?
To what extent were QI goals achieved? Sustained? Do the same QI Projects need to be extended?
Was there the right mix of staff members on the QI Project teams?
Were stakeholders informed of and participate in quality activities?
Was training provided?
Were performance measures reflective of standards of care?
Were your results in the expected range?
Were results shared with stakeholders?
To what extent can quality reports be generated to support the QM Committee’s decisions and program monitoring?
You will remember that part of the quality management process is an annual evaluation, the results of which are fed into next year’s quality management plan.
The quality management plan needs to state how this evaluation will be done, and how the information the evaluation provides will be used.
The evaluation needs to look at three things: Infrastructure effectiveness, QI activities, and performance measures.
Was the quality committee effective in improving HIV care and services? Does the quality infrastructure require further adjustment?
Were annual quality goals for quality improvement activities met? How effectively did you meet your goals?
Did the implementation of the annual work plan go as planned? Did you meet established milestones?
Were stakeholders informed about ongoing quality activities? Were staff and providers trained on QI methodologies and tools?
Were the measures appropriate to assess the clinical and non-clinical HIV care? Are the results in the expected range of performance?
In simple terms:
Did our infrastructure work?
Did we do what we said we were going to do?
Did we get the results we sought, and were we measuring the right things to understand this?
QM Plan Elements: Evaluation

25. Section II: Annual QM Program and QI Action Plan
How will we implement the QM Plan?
1. Presentation of data and results
Annual Improvement Goals: program
level and patient care level
3. QI Projects
4. Activity Timeline

26. II.1. Presentation of Data and Data Analysis
Data and analysis from performance measurement data (patient care)
HIVQUAL data
EHR data
Patient satisfaction surveys
Data and analysis from QM Program evaluation
Organizational quality assessment
Feedback from staff, consumers, QI Project Teams
Disparity data
Epidemiological data

28. HIV Monitoring
Core Indicator

29. Gynecology Exams
Core Indicator

30. II.2. Setting Quality Improvement Goals: Program Level and Patient Care
What are the priorities for your quality program?
Quality goals are endpoints or conditions toward
which your Quality Program will direct its efforts and
resources.
There are generally two levels of improvement goals:
QM Program level
Patient care level

31. QM Program Level
Based on your analysis and results of your organizational quality assessment, decide what particular aspects of your QM program can be improved during the next year.
Consider the following criteria:
What are our resources? Staff? Time?
What next steps can we take that is doable?

32. Example: QI Goals for Improving Infrastructure
Goal: To increase the effectiveness of the QM Program’s planning and monitoring system.
Form a QM Committee
QM Committee meets more frequently, at least quarterly
Write an annual QM Plan
Hold an annual planning session for the QM Committee to discuss results of the performance measurement data and set priorities for improvement

33. Develop your annual QI action plan
Examples contd.
Develop your annual QI action plan
Establish a performance measurement system:
select measures
train staff in data collection and entry
collect data
report results

34. Example: Improving Patient Care
Guidelines: When determining priorities try using the following criteria when making your selections:
Frequency: How many clients received/did not receive the standard of care/services?
Impact: What is the effect on patient health if they do not receive this care/services?
Feasibility: Can something be done about this problem with the resources available?

35. Example: QI Goals for Patient Care
To increase the annual rate of cervical cancer screening from 43% to 72% by the end of December, 2009.
To increase patient retention from 73% to 85% by the end of July, 2009.

36. QM Program Annual Action Plan
3 Goals:
QM Program – Infrastructure
Performance Measurement System
Quality Improvement
Quality
Management Program

37. Action Timeline

38. Goal: Effective implementation and monitoring of QM Program

39. Goal: Establish ongoing data collection and reporting to support performance measurement.

40. Goal: Improved quality of patient care as measured by specific performance indicators.

41. Resources
QM Plan Tips
Resources (web sites, materials)

42. Tips on Writing a QM Plan

43. Part 1: Quality Statement
Tips:
Be brief
Be visionary
Include internal and external expectations
Make references to external legislative requirements on quality management

44. Part 2: Quality Improvement Infrastructure
Tips
Limit the length of this section (not every detail is needed)
Avoid naming individuals (just job functions)
List internal and external stakeholders
List linkages

45. Part 3: Performance Measurement
Tips
In developing quality indicators, remember:
relevance
measurability
accuracy
improvability
Include the process for reviewing and updating indicators (who/when/how)
Include strategies to report and disseminate results and findings

46. Part 4: Annual Quality Goals
Tips
Pick only a few measurable and realistic goals annually (not more than 5)
Use a broad range of goals
Establish targets at the beginning of the year for each goal

47. Part 5: Participation of Stakeholders
Tips
List internal and external stakeholders and their functions/responsibilities
Include
Clinical providers
Non-clinical providers
Consumers
Representatives from agency, such as hospital, network, etc.
List proposed training opportunities for stakeholders

48. Part 6: Evaluation
Tips
Detail when and who is performing the evaluation
Compare annual QI goals with year-end results
Use findings to plan next year’s activities; learn and respond from past performance
Routinely use organizational assessment tools

49. 10 QM Plan Tips
Do not reinvent the wheel, use established frameworks to get started
‘Steal Shamelessly, Share Senselessly’
Size does not matter!
80% planning, 20% writing
A few visionary annual goals are better than plenty of useful ones
Be inclusive, even it takes longer to get your final QM plan
What concrete tips might help when writing a quality management plan? Here are 10 steadfast rules to help guide you.
Sample plans are out there. Use the references at the end of this Tutorial to find them, and begin there.
As with so many things in quality, make use of what others have done and be willing to share what you’ve accomplished, to help others.
It doesn’t matter how long it is. Substance matters more.
Think through what you want to do before you start to write. Don’t obsess over the writing, it’s the planning that matters.
Use the plan-writing process to push your organization forward.
10 QM Plan Rules

50. 10 QM Plan Tips (cont.)
If you did not update the plan throughout the year, you probably did not look at it
A ‘perfect’ plan is never written
Plans are only as good as their implementation
Get started! (Start a first draft. If you have one that hasn’t been updated, take it to your next QM Committee mtg)
Involve the people who need to be involved. They will make the plan a living document, rather than something that’s just a hoop to be jumped through.
Here’s a tip to make sure your plan stays real – if you’re not using it regularly, haul it out and talk about it. It should be a living guide.
Don’t let the perfect be the enemy of the good. If it works for your organization, it’s fine.
Plans are only as good as their implementation.
To use a popular cliché, just do it! All the planning in the world is for not if you do not take action.
10 QM Plan Rules

51. Resources HIVQUAL Workbook
NQC Quality Academy Online Tutorial on QM Plans (
NQC QM Plan Review Checklist
Example QM Plans from others
HIVQUAL Group Learning Guide
Measuring Clinical Performance: A Guide for HIV Health Care Providers
HRSA’s Quality Management TA Manual (9-Step Model)

52. THANK YOU
Many of these materials can be sent electronically so please contact Nanette or Susan to request them.