1. ADAP Clinical Quality Management Tutorial Two: How to Develop an ADAP Quality Management Plan
The Health Resources and Services Administration, HIV/AIDS Bureau (HRSA/HAB), the National Alliance of State and Territorial AIDS Directors (NASTAD) and the National Quality Center (NQC) are pleased to bring you this web-based tutorial, an online learning opportunity on key quality management concepts focusing on AIDS Drug Assistance Programs. NASTAD represents the nation’s chief state health agency staff who have programmatic responsibility for administering HIV/AIDS healthcare, prevention, education, and supportive service programs funded by state and federal governments. The NASTAD Care and Treatment team provides peer-based technical assistance to Ryan White Part B and ADAP programs in all states and territories on a wide array of topics. The NQC provides no-cost, state-of the-art technical assistance on quality management for all Ryan White Program grantees to improve the quality of HIV care nationwide. Both NASTAD and NQC are funded through HRSA/HAB Cooperative Agreements.
Please note that each Tutorial is just a piece of a larger puzzle. You will need all of the information to truly understand how your organization can create a successful quality management plan. Additionally, we strongly encourage you to review the NQC Quality Academy Tutorials as part of the training for quality management.
This Tutorial is titled:
How to Develop an ADAP Quality Management Plan

2. Learning Objectives: You Will Learn About…
Key terminology
Crucial elements of a quality management plan
Quality statement
Quality improvement infrastructure
Performance measurement and HAB ADAP performance measures
Annual quality goals
Engagement of stakeholders
Evaluation
Ten quality management rules for success
Putting your plan into practice
To sustain quality improvement gains, a sound quality management infrastructure is needed. Part of this infrastructure is to write a quality management plan with annual updates. You can find an in-depth tutorial on this topic on the NQC’s Quality Academy website. We encourage you to complete that tutorial to learn about the important components of a quality management (QM) plan; this introduction will give you a general background that will assist with ADAP-specific quality planning.
In today’s tutorial we will highlight some key components to developing an ADAP quality management plan with ADAP specific examples. This tutorial will also explore ways ADAP quality measures can be incorporated into a larger Ryan White Part B or HIV Care quality management plan. We will start by providing you with key terms necessary for writing and updating a QM plan.
Any quality management plan needs structure so we will spend some time outlining important elements that we suggest make up a good quality management plan.
Although HRSA/HAB has developed four ADAP performance measures for your use, it is imperative that you have a strong understanding of quality concepts and processes so that you can track your ADAPs progress on each measure. This knowledge will facilitate implementation of additional quality measures appropriate to each state’s ADAP program, clients, and infrastructure.
This tutorial will provide an overview of:
What is included in a quality management program of which ADAP components are only one part; and
How to write a quality management plan that includes ADAP specific activities
We appreciate your participation and hope that you find this training valuable to your organization’s success. Enjoy.

3. Quality Management Program
Encompasses all quality activities, including the formal 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).
Before we can talk about the elements of an ADAP quality management plan, let’s review some basic quality terminology to make sure we are all speaking the same language.
The quality management program is the big picture: it’s everything you do around quality in your program. An ADAP may create a stand-alone quality management program, or it may find it more feasible to include ADAP quality activities as one component of a larger organizational quality management program. Either option can work effectively depending upon what resources exist to create, manage, and evaluate the quality management program. Regardless of the overall structure, a quality management program identifies, defines, or describes:
Who is involved;
What will be measured;
What you are trying to improve;
How you are trying to make these improvements; and
The appropriate infrastructure to support these activities.

4. Quality Management Plan
A quality management plan is a written document that outlines the 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.
The quality management plan is the written document describing how the quality management program works, what gets done, who does it and how.
For the purposes of this tutorial, we will use the ADAP performance measures developed by the HIV/AIDS Bureau as examples for inclusion in the QM plan. This Tutorial will focus on what should make up this quality plan.

5. Elements of a Quality Management Plan
Quality statement
Quality infrastructure
Performance measurement
Annual quality goals
Engagement of stakeholders
Evaluation
Now that we are all on the same page, we are going to discuss the elements of a written quality management plan.
The quality management plan should contain the six elements listed here.
How ADAP expectations are incorporated into each of these elements will vary program to program.
Let’s begin by talking about the quality statement.

6. Quality Statement: What Do We Want to Be?
Be brief and be visionary
Include internal and external expectations
Specify who are you serving
ADAP Example
…to provide access to appropriate HAART medications for the treatment of HIV/AIDS for all ADAP eligible clients in the state.
General Example
…to provide case management services
to all Ryan White Part B eligible clients in the state.
If the ADAP creates a stand-alone Quality Management Plan and Quality Management Program, then the quality statement should describe what the ADAP wants to be for its clients and its community. The quality statement is essentially a brief mission statement describing the end goal of the ADAP quality program to which all other activities are directed.
If the ADAP program is one component of a larger HIV or Part B quality program and plan, the quality statement will be more global to encompass all HIV care and treatment programs in the state.

7. Quality Management Plan Infrastructure
Leadership – who is responsible for each quality management initiative?
Accountability – when does the quality committee meet? Who do committee members report to? What are their responsibilities?
Quality committee(s) structure – who serves on the committee, chairs the committee? What is the length of term on the committee?
Resources – what resources are available to support the quality committee’s work?
The next element of the ADAP-specific quality management plan contains a written description of the infrastructure that supports the quality management program and its work. The infrastructure statement should define who serves on the committee, how often the committee meets, what resources are available, and the main reporting relationships and responsibilities as well as the responsibilities of the leadership.
Since ADAP may only be a portion of the larger Part B program, staff positions from the ADAP or who are linked to the ADAP should be defined in the statement as appropriate. Conversely, if ADAP creates a standalone quality program, the infrastructure statement should specify how it interfaces with other Part B or HIV program quality activities.

8. Performance Measurement: How Will We Assess Progress?
Identify what’s important
Develop ways to measure
Include process, outcome, and satisfaction measures
Identify if your program has data to measure progress and how accurate, reliable and valid is the data
A good indicator consists of:
Relevance
Measurability
Accuracy
Improvability
Performance measurement is necessary to track progress towards the end goal of improvement.
There are three steps to measuring performance:
First, identify the critical aspects of services the ADAP program provides
Second, determine what data needs to be collected to measure progress. Many QM teams struggle with their data and questions such as: determining if the data is thorough and reliable; if we don't collect this data, how will we begin to collect it; what are the data elements, who has the data, who is responsible for the data and who can evaluate the data?
Third, develop indicators that measure the progress of the ADAP services to determine how you are doing on these important aspects of care and service. Adopt existing ADAP measures where possible.

9. HRSA/HAB ADAP Performance Measures
The following are HAB’s Performance Measures for ADAP:
Percent of ADAP applications approved or denied for new ADAP enrollment within 14 days (two weeks) of ADAP receiving a complete application in the measurement year
Percentage of ADAP enrollees who are reviewed for continued ADAP eligibility two or more times in the measurement year
Percentage of new anti-retroviral classes that are included in the ADAP formulary within 90 days of the date of inclusion of new antiretroviral classes in the PHS Guidelines for the Use of Antiretroviral Agents in the HIV-1-infected Adults and Adolescents during the measurement year
Percent of identified inappropriate antiretroviral (ARV) regimen components prescriptions that are resolved by the ADAP program during the measurement year.
In January 2010 HRSA’s HIV/AIDS Bureau released four ADAP Performance Measures.
Although it is not mandatory that you implement the HAB ADAP performance measures, your effort to implement continuous tracking of these measures will be worth the effort. Implementing a system to track your progress on these four measures will help your program meet the expectations of the current Ryan White Program legislation to incorporate clinical quality management (outlined in Tutorial 1).
Throughout this tutorial, these specific ADAP performance measures will be mentioned and provided as examples; however, each ADAP should consider what additional performance measures can be developed to improve client health outcomes in individual jurisdictions.

10. ADAP Example: Performance Measurement
Percent of ADAP applications approved or denied for new ADAP enrollment within 14 days (two weeks) of ADAP receiving a complete application.
An ADAP working on improving this performance measure would use the current year as the baseline. For example - in 2010, 87% of applications were approved or denied within 14 days. In 2011 – 92% and in 2012 – 95%.
Using the PDSA cycle, the ADAP would describe the program improvements they will make to spur the increase in percentage of applications processed within 14 days.
To best understand what an ADAP performance measure would look like; let’s take one measure from the recently developed HAB ADAP performance measures.
The measure is focused on a timely review for ADAP eligibility to ensure expedited access to medications.
How do I determine if this is a good measure? Ask questions:
What do you want to measure?
Is this measure measurable given the resources available?
Is this measure relevant to my program?
Do we have the resources to measure this program activity effectively?
ADAPs who implement this measure within their quality management plan should set an annual goal of the percent of applications the program will approve or deny for eligibility within 14 days of receipt of a complete application. There are national benchmarks available but more importantly each ADAP should determine their annual goals for improvement to show success of this measure and improved access for clients to medications.
The task of developing indicators may seem challenging, but the basic concept is straightforward: measure things that matter.

11. Annual Quality Goals: What Are the Priorities for the ADAP Quality Program?
Quality goals are endpoints or conditions toward which a quality program will direct its efforts and resources.
Three things to look at in designing goals:
Frequency: How many clients received and how many did not receive the standard of care/services?
Impact: What is the effect on clients’ health if they do not receive the appropriate care/service?
Feasibility: Can something be done about this problem with the resources available?
It is important to understand that with performance measurement comes the ability to track progress. The next element of your quality management plan - the annual quality goal - is what your ADAP program can track progress towards.
When determining what additional performance measures you will implement, consider what the ADAP needs to accomplish this year.
These goals should be set with frequency, impact, and feasibility in mind.
In setting these goals, your ADAP program is committing to take action.
And remember, achieving these goals should help the larger HIV or Ryan White Part B quality management program reach its 3-5 year strategic plan objectives, and through that, its vision.

12. Tips for Engaging Stakeholders
Outline stakeholder functions/responsibilities
Include
Providers
ADAP clients
Other Ryan White Program Parts
List proposed training opportunities
Share your improvements with stakeholders and celebrate your successes
When determining who will be a part of the quality management program, it is important to include both internal and external stakeholders. The structure an ADAP uses to implement its quality management program may determine what stakeholders with specific ADAP knowledge will be involved in the process. Since ADAPs typically use a Medical Advisory Committee that includes a variety of stakeholders, this Committee may provide a pool of informed stakeholders who could assist in the quality management program at a variety of levels.
From the perspective of a more comprehensive Ryan White Part B or HIV Care Quality Program, anyone with an interest in the success of the program is a stakeholder and should be included as feasible. The quality management plan should clarify how staff, consumers, community advisory board members, and others will be engaged in the work of the QM program and how data will be analyzed and shared.
It is important to note here that your stakeholders will want to be informed about program improvements. They will want to see that program challenges, such as delays in processing applications, for example, are being resolved. Celebrating improvements, even small ones, will affirm that their work matters because the program is continually delivering better services to people living with HIV/AIDS. Be creative in sharing good news, and celebrate your successes.

13. Evaluation: How Will We Assess the Quality Management Program’s Performance?
Infrastructure
Did we improve ADAP services?
Do we require further adjustment?
QI activities
Were goals achieved?
How effectively?
Performance measures
Was the work plan executed as designed?
Were established milestones hit?
Were stakeholders informed?
Are results in the expected range?
You will remember that part of the quality management program is an annual evaluation, the results of which are fed into next year’s quality management plan.
A crucial part of the quality management plan is a description of how and when this evaluation will be done, by whom, and how the information the evaluation provides will be used.
The evaluation should address three factors:
Infrastructure effectiveness; QI activities; and Performance measures.
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? Were we measuring the right things? Was the quality management committee effective in implementing a quality improvement project? Does the quality infrastructure require further adjustment? Were annual quality goals for quality improvement activities achieved? How effectively were goals met? Did the implementation of the annual work plan go as planned? Did you meet established milestones? Were the measures appropriate to assess ADAP services? Were the results in the expected range of performance?

14. The 10 Quality Management Plan Rules for Success
Do not reinvent the wheel, use established frameworks to get started
Establish targets for goals and measure how you meet the targets
Length of the plan does not matter
80% planning, 20% writing
A few visionary annual goals are better than plenty of useful ones
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.

15. The 10 Quality Management Plan Rules for Success
Be inclusive, even if it takes longer to get your final QM plan
If you have not touched your plan in the last 6 months, bring it to the next quality committee meeting
There is no such thing as a perfect plan
Plans are only as good as their implementation
Get started
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.

16. Conclusion: Elements of a Quality Management Plan
Quality statement
Quality infrastructure
Performance measurement
Annual quality goals
Engagement of stakeholders
Evaluation
In conclusion, let’s review the six key elements of a quality management plan. Your plan should include a quality statement, quality infrastructure, performance measurement, annual quality goals, engagement of stakeholders, and year end evaluation. Remember, the results of this year’s plan will go into the formation of next year’s plan. Your year-by-year results should support your 3-5 year quality management strategy, or vision. Remember to engage all stakeholders by sharing your measurable progress for each measure on at least an annual basis.
For ADAP staff interested in a comprehensive tutorial on performance measurement, the resources listed at the close of this tutorial will guide you to the NQC Quality Academy website. We encourage you to complete the general tutorial on “How to Write a Quality Management Plan” for a more complete understanding of this important process.

17. Test Question
Which of the following is not one of the four HRSA/HAB ADAP Performance Measures?
Application determination
Eligibility recertification
Financial forecasting
Formulary
Inappropriate antiretroviral regimen components
Before we end, let’s test your understanding of HRSA/HABs Performance Measures for ADAP. Select the answer that best answers the question, after selecting your answer, click the submit button to continue.
(The Answer is C – Financial forecasting)

18. Financial forecasting
Test Question
The correct answer is:
Financial forecasting
Before we end, let’s test your understanding of HRSA/HABs Performance Measures for ADAP. Select the answer that best answers the question, after selecting your answer, click the submit button to continue.
(The Answer is C – Financial forecasting)

19. Resources
Building Capacity of Statewide Quality Management Programs - NQC Guide for Ryan White HIV/AIDS Program Part B Grantees
For guidance in teaching small groups how to develop a quality improvement management plan, see the HIVQUAL Group Learning Guide "Quality Improvement Management Plan" exercise. You can download this publication at
For examples and other general tips: The HIVQUAL Workbook, especially pp You can download this publication at
As you can see, there are many sources of information available on quality management plans. Take some time to review this information. Clicking any of the links will launch a separate window. You can bookmark these sites and then simply close down those browser windows to return to this Tutorial. Once you are finished reviewing this material, click the continue button to proceed.

20. For further information, contact: For further information, contact:
National Alliance of State and Territorial AIDS Directors
444 North Capitol Street, NW
Suite 339
Washington D.C
Phone:
Fax:
Or visit us online at:
For further information, contact:
National Quality Center
New York State Dept. of Health
90 Church Street, 13th floor
New York, NY
Work:
Fax:
Or visit us online at NationalQualityCenter.org
This concludes Tutorial 2, “How to Develop an ADAP Quality Management Plan.” As you can see, there is a lot to learn about improving quality. If you have not done so yet, please check out the other training resources we have available for you. For additional resources on quality in the Ryan White Program, please contact the National Quality Center. For additional assistance with ADAP, please contact NASTAD. You can also contact, or visit us online. Thank you for your time today and we look forward to hearing from you soon. 20