1. Section 4 Processes & Projects Section 1 Quality Statement Section 2 Quality Infrastructure Section 3 Performance Measures & Annual Goals Section 7 Communicating Reports & Initiatives Section 6 Stakeholder Participation Section 5 Yearly Program Activities Section 8 Evaluation Writing a Quality Management Plan Introduction GlossaryCredits/Contact

2. Statement-Description Quality Statement Description Additional Resources Tips and Tools Example The quality plan begins with a quality statement. It should include a brief purpose statement describing the end goal of your HIV quality program and a shared vision to which all other activities are directed. Assume an ideal world and ask yourself, “What do we want to be for our clients and our community?”

3. Statement-Tips&Tools Quality Statement Description Additional Resources Tips and Tools Example Quality statements should: Be brief Be visionary Include internal and external expectations Make references to Ryan White legislative requirements for quality management

4. Statement-Example Quality Statement Description Additional Resources Tips and Tools Example Click to open

5. Statement-Additional Resources Description Additional Resources Tips and Tools Example Additional Resources for Writing QM Plans National Quality Center (NQC) Quality Academy: The Quality Management Plan (lesson 5)The Quality Management Plan NQC Resources: How to develop and update written quality management plansHow to develop and update written quality management plans Health Resources and Services Administration: Developing and implementing a QI planDeveloping and implementing a QI plan Quality Statement

6. Infrastructure-Description Quality Infrastructure Description Additional Resources Tips and Tools Example Quality infrastructure includes the critical aspects of funded services. These should be relevant, measurable, and improvable. If available, you will want to include: Leadership: those responsible for QM initiatives Quality committee structure: those who serves on the QM committee as chair and or as coordinators Standards: the framework and expectations for the QM program Roles and responsibilities: key persons, organizations, major stakeholders Resources: resources available/used by the QM program Capacity building: how quality is being integrated into all functions/aspects of the program

7. Infrastructure-Tips&Tools Quality Infrastructure Description Additional Resources Tips and Tools Example The quality infrastructure section of the quality plan should include: 3 – 5 pages Job Functions All stakeholders and responsibilities Linkages/networks

8. Infrastructure-Example Quality Infrastructure Description Additional Resources Tips and Tools Example Click to open

9. Infrastructure-Additional Resources Description Additional Resources Tips and Tools Example Quality Infrastructure Additional Resources for Developing QM Infrastructure National Quality Center (NQC) Quality Academy: QM infrastructure—how to establish a quality management committeeQM infrastructure NQC Quality Academy: Integrating quality into all aspects of an organization: Integrating quality into all aspects of an organization NQC Quality Academy: Systems thinkingSystems thinking Health Resources and Services Administration: Redesigning a system of care to promote QIRedesigning a system of care to promote QI

10. PM & Annual Goals-Description Performance Measures & Annual Goals Description Additional Resources Tips and Tools Example Performance measures is the system used to track desired client outcomes and the program’s progress towards achieving those outcomes. These outcomes should be as good as or better than national treatment standards. Annual goals are drawn from the list of performance measures. Key stakeholders decide which performance measures to focus upon improving for the year.

11. PM & Annual Goals-Tip&Tools Performance Measures & Annual Goals Description Additional Resources Tips and Tools Example Performance Measures: Identify critical aspects of care and services provided, and Develop indicators, and measure how well the program is progressing towards achieving desired outcomes in care and service Choose measures from reputable sources (such as HRSA, CDC, HCS, etc.) Obtain data from multiple sources to ensure accurate reporting Annual goals: Key stakeholders should be responsible for choosing a few goals each year (no more than 5) Benchmarks should be set for each chosen performance measure Improvement activities for the year should be designed to improve chosen performance measures

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13. PM & Annual Goals-Additional Resources Description Additional Resources Tips and Tools Example Additional Resources for Creating Measures and Annual Goals National Quality Center (NQC) Quality Academy: How to develop ADAP quality indicatorsHow to develop ADAP quality indicators NQC Resources: Measuring performance in HIV care—how to collect performance data and examples of HIV quality indicatorsMeasuring performance in HIV care NQC Resources: Measuring clinical performance—a guide for HIV health care providersMeasuring clinical performance NQC Resources: Data collection toolsData collection tools Institute for Healthcare Improvement: Science of improvement—establishing measuresScience of improvement—establishing measures Health Resources and Services Administration (HRSA): Performance management and measurementPerformance management and measurement HRSA: Management data for performance improvementManagement data for performance improvement Performance Measures & Annual Goals

14. Processes & Projects-Description Processes & Projects Description Additional Resources Tips and Tools Example Your QM Plan should explain the processes you use for selecting, documenting and measuring improvement projects. Quality improvement (QI) processes refer to the criteria for selecting improvement projects, documenting projects/status/results, tools and techniques used for improvement activities (i.e., Lean, PDSA, Model of Improvement, etc.), feedback and evaluation of projects. QI projects are systematic and documented activities designed to improve programmatic processes and/or outcomes of processes.

15. Processes & Projects-Tips&Tools Processes & Projects QI processes Describe the process for how you choose and prioritize projects Describe how you monitor and document your projects Describe how you ensure your projects can be linked to specific performance measures, annual goals, strategic goals or the mission statement Describe what quality improvement tools you use for projects QI activities List program activities and how they were selected Describe your improvement projects, and what project teams and quality improvement tools you will use Description Additional Resources Tips and Tools Example

16. Processes & Projects-Example Processes & Projects Description Additional Resources Tips and Tools Example Click to open

17. Processes & Projects-Additional Resources Additional Resources for QM Processes and Projects National Quality Center (NQC) Quality Resources: Conducting quality improvement activities— essentials to implementing quality improvement projectsConducting quality improvement activities NQC Quality Resources: The improvement guideThe improvement guide The LeanOhio information kitLeanOhio information kit The Institute for Healthcare Improvement: Model of improvementModel of improvement Description Additional Resources Tips and Tools Example Processes & Projects

18. Yearly Program Activities-Description Yearly Program Activities Description Additional Resources Tips and Tools Example Yearly program activities are improvement projects designed to improve the program (and ultimately improve upon client outcomes). Activities and measures are chosen based on pre- determined criteria. Improvement projects must be measurable and align with the agency mission.

19. Yearly Program Activities-Tips&Tools Yearly Program Activities List your criteria for choosing projects, such as financial benefits, efficiency, etc. and who will be involved in prioritizing projects Create SMART objectives: specific, measurable, attainable, relevant, and timely Document your process for tracking projects Explain the processes you will use and how your objectives will be linked to specific performance measures Include the who, when, and how about each activity Determine how you will be reporting your measures to key stakeholders Description Additional Resources Tips and Tools Example

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21. Yearly Program Activities-Additional Resources Additional Resources Health Resources and Services Administration : Readiness assessment & developing project aimsReadiness assessment & developing project aims National Quality Center: QM program assessment toolsQM program assessment tools Description Additional Resources Tips and Tools Example Yearly Program Activities

22. Stakeholder Participation-Description Stakeholder Participation Description Additional Resources Tips and Tools Example Stakeholders refer to anyone who has a concern or interest in something, and who may be affected in some way by your RW QM program actions, objectives, or policies. Address how different stakeholders are involved in your QM program: How are internal and external stakeholders involved in/impacted by your program? (impacts may be negative or positive.) How are your quality improvement activities communicated to them? What opportunities are you providing for them to learn about quality?

23. Stakeholder Participation-Tips&Tools Stakeholder Participation Create a chart that lists internal and external stakeholders and their functions/responsibilities Include: Providers Consumers Sub-grantees Other Ryan White CARE Act Parts Resources impacted by QM program (e.g. databases managed by IT, transportation managed by DAS, etc.) List proposed training opportunities for stakeholders Description Additional Resources Tips and Tools Example

24. Stakeholder Participation-Example Stakeholder Participation Description Additional Resources Tips and Tools Example Click to open

25. Stakeholder Participation-Additional Resources Additional Resources for Engaging Stakeholders National Quality Center Quality Academy: Engaging staff and consumers in QI workEngaging staff and consumers in QI work Project Management Institute: Engaging stakeholders for project successEngaging stakeholders for project success Health Resources and Services Administration: Improvement teamsImprovement teams Description Additional Resources Tips and Tools Example Stakeholder Participation

26. Communicating Reports & Initiatives- Description Communicating Reports & Initiatives Description Additional Resources Tips and Tools Example Integrating QI into an organization and culture requires communication with all stakeholders (internal and external) about successes and updates. Storyboards are a great tool for sharing this information. Your successes become their successes and increases both QI visibility and perceived value within the organization.

27. Communicating Reports & Initiatives- Tips&Tools Communicating Reports & Initiatives Compile a list of your stakeholders, important information, and important dates, then create a chart with the following columns: What you will be communicating (e.g. templates, data, reports, etc.) Who will be communicating it (supervisor, chairperson, QI team lead, etc.) How you will communicate it (e.g. electronic, mail, teleconference, etc.) To whom you will communicate the information (agency, committee, etc.) When (or how often) you will communicate it Description Additional Resources Tips and Tools Example

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29. Communicating Reports & Initiatives-Additional Resources Additional Resources Healthcare Information & Management Systems Society/Robert Wood Johnson Foundation: Lessons learned in public reporting: deciding what to report Lessons learned in public reporting: deciding what to report Quality Assurance & Performance Improvement: Storyboard guide for PIPs (performance improvement project)Storyboard guide for PIPs Description Additional Resources Tips and Tools Example Communicating Reports & Initiatives

30. Evaluation-Description Evaluation Description Additional Resources Tips and Tools Example The evaluation explains how your QM program will assess it’s own performance in terms of: Infrastructure: how effective is your existing infrastructure? Can it be improved? quality improvement activities: were goals met? If so, how effective were your activities? Outcome performance measures: were your measures appropriate for assessing clinical and non-clinical HIV care? Were goals met? Were stakeholders informed? Was training provided? Improvement: how can your QM program improve upon the prior year’s results?

31. Evaluation-Tips&Tools Evaluation Explain who is performing your QM program’s evaluation and when Compare your annual quality goals with your year-end results Use your findings to plan next year’s activities; learn and respond from your past performance Routinely use organizational assessment tools like those provided by the National Quality Center Description Additional Resources Tips and Tools Example

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33. Evaluation-Additional Resources Additional Resources for evaluating your QM program National Quality Center Quality Academy: QM program assessment toolsQM program assessment tools Centers for Disease Control: A framework for program evaluationA framework for program evaluation Description Additional Resources Tips and Tools Example Evaluation

34. Credits & Contact Information Software Microsoft PowerPoint 2013 Software Instructional Designer Sponsor Credits & Contact Contact information Instructional Designer Jamie L. Perez, M.S., M.Ed. Sponsor Ohio Department of Health HIV Care Services Section 246 North High Street, Columbus, OH 43215 http://www.odh.ohio.gov/hcs Contact Information hcs@odh.ohio.gov 614-466-6374 Date available May 2015