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1National Quality Center (NQC) NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management Plans April17, 2008 Nanette Brey Magnani and Susan.

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Presentation on theme: "1National Quality Center (NQC) NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management Plans April17, 2008 Nanette Brey Magnani and Susan."— Presentation transcript:

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

2 2National Quality Center (NQC) 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 3National Quality Center (NQC) Agenda 9:00Welcome. Introductions Review agenda and materials. 9:15Interactive 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. 11:00Cut and paste highlighted parts into a draft QM Plan. 11:30Large group sharing and next steps. 11:50Feedback and evaluation. 12:00Adjourn.

4 4National Quality Center (NQC) Infrastructure enhances systematic implementation of improvement activities Infrastructure

5 5National Quality Center (NQC) 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 6National Quality Center (NQC) Grantee-wide Vision Strategic QM Plan (3-5 yrs) QM Plan Annual Goals Action Plan Implementation Annual Evaluation

7 7National Quality Center (NQC) Format and Components of a QM Plan Section I: Description – Relatively unchanged from year to year 1.Quality statement 2.Infrastructure 3.Performance measurement 4.Annual quality goals 5.Stakeholder participation and development 6.Evaluation

8 8National Quality Center (NQC) QM Plan format and components contd. Section II: Annual QI Action Plan– Changes from year to year 1.Presentation of data and results 2.Annual Improvement Goals/Objectives 3.QI Projects 4.Activity Timeline

9 9National Quality Center (NQC) 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 cant attend meetings due to time, distance, etc.)

10 10National Quality Center (NQC) (Title of Program) Quality Management Plan Section 1: Description of ____ HIV Quality Management Program

11 11National Quality Center (NQC) 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 12National Quality Center (NQC) 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 13National Quality Center (NQC) 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 14National Quality Center (NQC) 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 15National Quality Center (NQC) 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 16National Quality Center (NQC) 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 17National Quality Center (NQC) 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 18National Quality Center (NQC) Waterbury Hospital Accountability Diagram Internal Communication WHICH QM Committee Ryan White Program Director Consumer Advisory Group HIV Care Team

19 19National Quality Center (NQC) Plan for Communication Internal communication (Monthly): The QI programs progress is on the agenda of the monthly HIV care team and the department of medicines 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 20National Quality Center (NQC) Hospital Accountability Diagram External Communication (annually) WHICH QI Committee Ryan White Program Director Dept of Medicine Director -HRSA -RW Part A office Waterbury Hosp QM Committee Waterbury Hosp Executive Management Team

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

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

23 23National Quality Center (NQC) 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 24National Quality Center (NQC) I.6: Evaluation How will we evaluate our overall performance as a program? Infrastructure QM Plan Elements: Evaluation 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 Committees decisions and program monitoring?

25 25National Quality Center (NQC) Section II: Annual QM Program and QI Action Plan How will we implement the QM Plan? 1. Presentation of data and results 2.Annual Improvement Goals: program level and patient care level 3. QI Projects 4. Activity Timeline

26 26National Quality Center (NQC) 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

27 27National Quality Center (NQC)

28 28National Quality Center (NQC) HIV Monitoring Core Indicator

29 29National Quality Center (NQC) Gynecology Exams Core Indicator

30 30National Quality Center (NQC) 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 31National Quality Center (NQC) 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 32National Quality Center (NQC) Example: QI Goals for Improving Infrastructure Goal: To increase the effectiveness of the QM Programs 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 33National Quality Center (NQC) 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 34National Quality Center (NQC) 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 35National Quality Center (NQC) Example: QI Goals for Patient Care To increase the annual rate of cervical cancer screening from 43% to 72% by the end of December, To increase patient retention from 73% to 85% by the end of July, 2009.

36 36National Quality Center (NQC) QM Program Annual Action Plan 3 Goals: QM Program – Infrastructure Performance Measurement System Quality Improvement Quality Management Program

37 37National Quality Center (NQC) Action Timeline

38 38National Quality Center (NQC) Goal: Effective implementation and monitoring of QM Program

39 39National Quality Center (NQC) Goal: Establish ongoing data collection and reporting to support performance measurement.

40 40National Quality Center (NQC) Goal: Improved quality of patient care as measured by specific performance indicators.

41 41National Quality Center (NQC) Resources QM Plan Tips Resources (web sites, materials)

42 42National Quality Center (NQC) Tips on Writing a QM Plan

43 43National Quality Center (NQC) Part 1: Quality Statement Tips: Be brief Be visionary Include internal and external expectations Make references to external legislative requirements on quality management

44 44National Quality Center (NQC) 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 45National Quality Center (NQC) 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 46National Quality Center (NQC) 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 47National Quality Center (NQC) 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 48National Quality Center (NQC) 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 years activities; learn and respond from past performance Routinely use organizational assessment tools

49 49National Quality Center (NQC) 10 QM Plan Tips 1.Do not reinvent the wheel, use established frameworks to get started 2.Steal Shamelessly, Share Senselessly 3.Size does not matter! 4.80% planning, 20% writing 5.A few visionary annual goals are better than plenty of useful ones 6.Be inclusive, even it takes longer to get your final QM plan 10 QM Plan Rules

50 50National Quality Center (NQC) 10 QM Plan Tips (cont.) 7.If you did not update the plan throughout the year, you probably did not look at it 8.A perfect plan is never written 9.Plans are only as good as their implementation 10.Get started! (Start a first draft. If you have one that hasnt been updated, take it to your next QM Committee mtg) 10 QM Plan Rules

51 51National Quality Center (NQC) 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 HRSAs Quality Management TA Manual (9- Step Model)

52 52National Quality Center (NQC) THANK YOU Many of these materials can be sent electronically so please contact Nanette or Susan to request them.

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