1. Developing a Quality Management Plan Sheila Boyle, ACRN, MS Process Improvement Coordinator AIDS Program, Albany Medical College (518) 262-4025 BoyleS@mail.amc.edu

2. Background Academic, hospital-based, HIV clinic RWCA Titles II, III, IV Comprehensive services Primary Care, Adherence, Case Management, Research, Nutrition, Mental Health, Substance Abuse, Dental 1200+ patients annually Hispanic (12%), Black (37%), White (49%); Male (64%), Female (36%), Transgender (0.5%); MSM (29%), IDU (17%), Heterosexual (39%); Medicaid (40%), Medicare (20%), ADAP (19%), Private (21%) Albany, NY

3. Elements of our Quality Management Plan Mission Statement Infrastructure Annual Goals Staff Involvement Consumer Involvement Evaluation and Updates

4. Developing a Quality Management Plan: Mission Statement Ensure the highest quality of patient care Focus on clinical outcomes

5. Developing a Quality Management Plan: Infrastructure Core team guides process removes barriers PI team Multi-disciplinary Monthly meetings Adhoc committees as needed Modified consensus Ultimate decision-making authority lies with medical director Hospital QIT

6. Developing a Quality Management Plan: Annual Goals 60% with Annual Exam 90% with Visit in the last 4 Months 60% with PPD Reading 80% with Pap 70% with Secondary Prevention Intervention Develop Mental Health Screening Tool and Diabetes Flow Sheet

7. Developing a Quality Management Plan: Staff Involvement Monthly PI updates at full staff meetings Quarterly PI updates and discussion with providers Interactive full-staff PI meetings 2x/year

8. Developing a Quality Management Plan: Consumer Involvement PI updates at each CAB (consumer advisory board) meeting CAB members provide feedback and suggestions on PI projects Several consumers on staff

9. Developing a Quality Management Plan: Evaluation and Updates Monthly review of progress toward goals Annual review of Quality Management Plan Use of Addendum Changes as needed

10. Developing Quality Management Plan: Albany Med’s Process IHI collaborative Formal documentation of QM plan Changes to plan Core team Decision-making process Staff involvement CAB involvement Addendum/Updates

11. Lessons Learned Evaluate the plan and revise prn Goals Decision-making process Structure Limit number of goals Know when to persevere Keep frontline staff involved