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Funded by HRSA HIV/AIDS Bureau What is Quality Improvement? What are the Quality Expectations from HAB? Aug 26, 2008 Clemens Steinbock, MBA Director, National.

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Presentation on theme: "Funded by HRSA HIV/AIDS Bureau What is Quality Improvement? What are the Quality Expectations from HAB? Aug 26, 2008 Clemens Steinbock, MBA Director, National."— Presentation transcript:

1 Funded by HRSA HIV/AIDS Bureau What is Quality Improvement? What are the Quality Expectations from HAB? Aug 26, 2008 Clemens Steinbock, MBA Director, National Quality Center Quality Institute Session 1

2 National Quality Center (NQC)2 Agenda - Opening Remarks - Overview and Introduction - Quiz – Group Activity - Principles of Quality Improvement - Scenario – Group Activity - HAB Expectations on Quality - QI Resources - Evaluations and Wrap-up

3 National Quality Center (NQC)3 “How can you make this topic entertaining and keep everyone from falling asleep?”

4 National Quality Center (NQC)4 What are my options? Use humor

5 National Quality Center (NQC)5 What are my options? Use my kids

6 National Quality Center (NQC)6 What are my options? or Use the audience… via the Audience Response System

7 Funded by HRSA HIV/AIDS Bureau Quiz

8 National Quality Center (NQC)8 1) What does CQI stand for? a)Community Quality Initiative b)Case Management Quality Ideas c)Continuous Quality Improvement d)Circular Quantum Invention

9 National Quality Center (NQC)9 2) Why does Quality Improvement become increasingly important in health care? a)Quality Improvement has been proven to be successful b)Increasing requirements by regulatory agencies c)Increasing accountability by programs for the quality of services d)All of the above

10 National Quality Center (NQC)10 3) What is the main difference between Quality Assurance and Quality Improvement? a)Quality Assurance uses mainly a team approach b)Quality Improvement focuses on statistical outliers for improvements c)Quality Assurance and Quality Improvement is practically the same d)None of the above

11 National Quality Center (NQC)11 4) What is the most important principle for Quality Improvement? Quality Improvement focuses on… a)Individual performers b)Routine measurement of performance c)Training of providers d)System’s issues

12 National Quality Center (NQC)12 5) Which of the following statement by HAB is INCORRECT? a)QM programs need to look beyond clinical services to consider both supportive services and outcomes b)QM programs assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines c)The primary focus of the QM program is on performance measurement to assess clinical and non-clinical services d)Quality is the degree to which a health or social support service meets or exceeds established professional standards and user expectations

13 National Quality Center (NQC)13 6) HAB describes the following characteristics of Quality Management Programs. Which ones are CORRECT? a)Be a systematic process with identified leadership, accountability and dedicated resources b)Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks c)Focus on linkages, efficiencies and client expectations in addressing outcome improvement d)Ensure that data are fed back into the quality improvement process to assure that goals are accomplished e)All of the above f)None of the above

14 National Quality Center (NQC)14 7) The following performance data report is presented: PPD 95%, GYN 85%, and PCP Prophylaxis 55%. You advise the program to continue to measure… a)only PCP Prophylaxis b)GYN and PCP Prophylaxis c)All three indicators

15 National Quality Center (NQC)15 8) The results of an adherence QI project are presented after 10 months of work, improving the rate to 98% and it was kept between 95%-100% for the last 4 months. You advise the program to… a)Discontinue routine measurements b)Switch to quarterly measurements c)Keep monthly measurements

16 National Quality Center (NQC)16 9) Due to the high rate of Mental Health screening (95%), the QI team stopped meeting but continued to measure the rate monthly. Recently the score declined. When should the MH QI team to re-start? a)90% b)80% c)70%

17 Funded by HRSA HIV/AIDS Bureau Couple more questions…

18 National Quality Center (NQC)18 What is your professional background? 1.Clinical Provider (MD, NP, PA) 2.Nurse 3.Case Manager/Social Worker 4.Administrator 5.Other 10

19 National Quality Center (NQC)19 How do you rate your own quality improvement knowledge? 1.Novice 2.Beginner 3.Intermediate 4.Proficient 5.Expert 10

20 National Quality Center (NQC)20 How do you rate your HIV Quality Management Program? 1.Not existing 2.Beginning 3.Sufficient 4.Good 5.Excellent 10

21 Funded by HRSA HIV/AIDS Bureau Quality Improvement Principles Clemens Steinbock, MBA NationalQualityCenter.org

22 National Quality Center (NQC)22 Success is achieved through meeting the needs of those we serve.

23 National Quality Center (NQC)23 Most problems are found in processes, not in people.

24 National Quality Center (NQC)24 Do not reinvent the wheel – Learn from best practices.

25 National Quality Center (NQC)25 Learn through small, incremental changes to achieve continual improvements.

26 National Quality Center (NQC)26 Actions are based upon accurate and measured data.

27 National Quality Center (NQC)27 Infrastructure enhances systematic implementation of improvement activities.

28 National Quality Center (NQC)28 Set Priorities and Communicate clearly

29 National Quality Center (NQC)29 Infrastructure Balance between Data Collection and Quality Improvement Activities

30 National Quality Center (NQC)30 ‘QI is not QA’ Quality AssuranceQuality Improvement Motivation Measuring compliance with standards Continuously improving processes to meet standards Means InspectionPrevention Focus Individuals, “bad apples”Processes and Systems Responsibility FewAll

31 National Quality Center (NQC)31 Three Faces of Quality Improvement AspectImprovementAccountability (Accreditation) Clinical Research Aim Improvement of careComparison, choice, reassurance, spur for change New knowledge Test observability Test observableNo test, evaluate current performance Test blinded Sample size “Just enough” data, small sequential samples Obtain 100% of available, relevant, data “Just in case” data Testing strategy Sequential testsNo testsOne large test Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.

32 National Quality Center (NQC)32 HAB’s Working Definition of Quality “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)

33 National Quality Center (NQC)33 In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment?

34 National Quality Center (NQC)34 Treatment of Scurvy Stephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004  In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster.  In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages.  In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in  From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy.  In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy.  In 1865 British Board of Trade adopted the policy for the merchant marine.

35 National Quality Center (NQC)35 How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article? 1.2 years 2.5 years 3.10 years 4.20 years

36 National Quality Center (NQC)36 Treatment of Ulcer – Marshall Timetable: 1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients 1981: Dr. Barry Marshall starts residency 1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer 1984: first publication in Lancet; presents treatment of ulcer with common antibioticum 1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. Marshall

37 National Quality Center (NQC)37 In a recent article in the Journal of Quality Improvement 92 QI projects were compared. What was the timeframe from problem identification to completion of first pilot? 1.23 days 2.60 days days days

38 National Quality Center (NQC)38 Survey of 92 Quality Improvement Projects in Journal of Quality Improvement Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11): days from problem identification to completion of first pilot  397 days from first team meeting to the end of first cycle  75 days to describe current situation in flowchart  62 days for data collection if change was improvement

39 National Quality Center (NQC)39 How can we accelerate change and improvements in HIV programs? Model for Improvement

40 National Quality Center (NQC)40 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? ActPlan StudyDo Model for Improvement Model for Improvement

41 National Quality Center (NQC)41 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement

42 National Quality Center (NQC)42 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement

43 National Quality Center (NQC)43 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement

44 National Quality Center (NQC)44 Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data The PDSA cycle for learning and improvement

45 National Quality Center (NQC)45 PDSA Cycle to incorporate the use of a new CM form Introduce new CM Intake/ Assessment Form Improve Access to HIV Primary Care AP SD A P S D AP SD D S P A DATA D S P A Cycle 1A: Adapt new CM form and test with one of Joanne’s patients Cycle 1B: Revise tool and test with Karl’s clients next Monday Cycle 1C: Present refined tool to all 3 case managers and document feedback Cycle 1D: Revise and test tool with all clients for one week Cycle 1E: Implement and monitor the standards

46 National Quality Center (NQC)46 Tips for PDSA Cycles “What change could you implement by next Tuesday?” Use the “Rule of 1”:  1 facility  1 office  1 provider  1 patient

47 National Quality Center (NQC)47 Tips for PDSA Cycles Volunteers at first Useful, not perfect, data Use “huddles” to report Learn from others (‘Steal shamelessly, Share senselessly’)

48 National Quality Center (NQC)48 References Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62 Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81 Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996 Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55

49 National Quality Center (NQC)49 HRSA’s 9-Step Model to Quality Goal of Manual: provide the tools to develop and implement a quality management program outline a step-by-step process that can be applied in any care setting applicable for both the experienced and non-experienced grantee Developed by HIV/AIDS Bureau Quality Institute

50 National Quality Center (NQC)50 HRSA’s 9-Step Model to Quality 1.Commit Leadership & Supportive Organizational Structure  Establish support of program leadership for Quality Management  Delineate specific QM responsibilities of staff 2.Establish Quality Management Plan  Establish Quality Committee to oversee the QM program  Develop an organizational QM plan which delineates goals and objectives for the QM program 3.Determine Performance Measures & Collect Data  Based on QM priorities, develop/adopt indicators to measure performance  Determine method of data collection and collect data

51 National Quality Center (NQC)51 HRSA’s 9-Step Model to Quality 4.Analyze Data  Analyze data and review the results  Identify areas where additional data is required 5.Develop Project-Specific CQI Plan  Establish project-specific QM team to improve specific aspects of care/services  Develop timeline for reporting findings and improvement 6.Study and Understand the Process  Utilize QI tools and techniques to understand the process  Report progress to senior leadership and staff

52 National Quality Center (NQC)52 HRSA’s 9-Step Model to Quality 7.Develop and Implement an Improvement Plan  Identify potential solutions to make improvement to the systems of care.  Try a small test of change and analyze results. 8.Re-measurement  Re-measure indicator after change has been implemented.  Determine need for and/or level of re-measurement on an ongoing basis. 9.Celebrate Success  Communicate results of the project to all levels of the organization  Congratulate team in public forum

53 National Quality Center (NQC)53 References HAB Quality Management Manual, HRSA HIV/AIDS Bureau website; hab.hrsa.gov/tools/QM

54 Funded by HRSA HIV/AIDS Bureau Scenario – Group Exercise Clemens Steinbock, MBA NationalQualityCenter.org

55 Funded by HRSA HIV/AIDS Bureau HAB Quality Expectations Clemens Steinbock, MBA NationalQualityCenter.org

56 National Quality Center (NQC)56 Update: Ryan White HIV/AIDS Treatment Modernization Act of 2006 – PL Reauthorized for which sunsets 9/30/09 Increased focus on living HIV and AIDS cases over the last calendar year Increased focus on expenditures for core medical services Increased focus on coordination and integration of care and prevention at federal, state and local levels Significant changes include: Part A eligibility definition, funding formulas, hold harmless percentages, annual sample audits, biannual reports to congress on funds expended, consequences for failure to comply See a Side-by-side comparison at

57 National Quality Center (NQC)57 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “The chief elected official/ grantee… shall provide for the establishment of a clinical quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services”

58 National Quality Center (NQC)58 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “RWCA grantees are directed to establish clinical quality management programs to …” “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…” “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV health services”

59 National Quality Center (NQC)59 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “RWCA grantees are directed to establish clinical quality management programs..” which include:  Development of a comprehensive clinical quality management infrastructure, including routine QM meetings with cross- functional representation  Description of QM program in a written quality plan, with a clear indication of responsibilities and responsible parties  Inclusion and involvement of key stakeholders in your quality program  Designated leaders for quality improvement and accountability

60 National Quality Center (NQC)60 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…” which includes:  Development and/or adaptation of quality indicators for key clinical and service categories  Routine performance measurement of key care aspects  Sharing of performance data with program staff  Use of data to improve the organization’s performance on key services

61 National Quality Center (NQC)61 Ryan White HIV/AIDS Treatment Modernization Act of 2006 “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV service…” that include:  Linking performance data results to quality improvement activities  Establishment of quality improvement teams with cross- functional representation  Integration of changes into routine program activities

62 National Quality Center (NQC)62 Key Characteristics of a Quality Management Program Patient-centeredness is a fundamental focus of quality care and undergirds the 5 characteristics that follow. 1. A systematic process with identified leadership, accountability, and dedicated resources available to the program 2. Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks 3. Focus on linkages, efficiencies and provider, and client expectation in addressing outcome improvement

63 National Quality Center (NQC)63 4. A continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities 5. Ensure that data collected are fed back into the quality improvement process to assure that goals are accomplished and that they are concurrent with improved outcomes Key Characteristics of a Quality Management Program (cont.)

64 National Quality Center (NQC)64 Quality Improvement Resources: Websites, Publications, Technical Assistance

65 National Quality Center (NQC)65 Quality Improvement Websites NationalQualityCenter.org HIV measures Change ideas Best practices Tools/resources Literature FAQ

66 National Quality Center (NQC)66 Quality Improvement Websites HIV QI publications Measures HIVQUAL Project Clinical guidelines Recent news and events

67 National Quality Center (NQC)67 Websites for Quality Improvement hab.hrsa.gov HRSA QI expectations QI Tools TA Resources

68 National Quality Center (NQC)68 QI Learning Resources Starting to Learn about Quality Improvement Measuring Quality of HIV Care Measurement Setting up a QM Infrastructure Writing a Quality Management Plan Conducting Quality Improvement Activities

69 National Quality Center (NQC)69 QI Teaching Resources Teaching Quality Improvement Fundamentals Teaching Performance Measurement Teaching QM Infrastructure Teaching Quality Improvement Activities Teaching Patients on Quality

70 National Quality Center (NQC)70 Consumer Involvement Training Materials Soliciting Patient Feedback Empowering Patients to Partner with their Health Care Providers Maintaining a Patient Health Record Best Practices for Consumer Involvement Teaching Providers about Patient Self-Management

71 National Quality Center (NQC)71 Quality Academy (Online Training Course) Online quality improvement training course – at no cost available 24/7 (also available on CD-Rom) Interactivity through test questions and online exercises 20 QI topics from beginner (e.g., QI 101, PDSA) to advanced levels (e.g., dealing with resistance) NationalQualityCenter.org/QualityAcademy

72 National Quality Center (NQC)72 Quality Improvement Publications

73 National Quality Center (NQC)73 Quality Improvement Publications

74 National Quality Center (NQC)74 Quality Improvement Publications

75 National Quality Center (NQC)75 Quality Improvement Publications

76 National Quality Center (NQC)76 Quality Improvement Publications

77 National Quality Center (NQC)77 Quality Improvement Publications

78 National Quality Center (NQC)78 Quality Improvement Publications

79 National Quality Center (NQC)79 HIVQUAL Software and QM Plan Checklist

80 National Quality Center (NQC)80 HIVQUAL Indicators – Adult and Adolescent ARV THERAPY MANAGEMENT HIV MONITORING ( CD4 and VL testing) HIV SPECIALIST CARE ANTIRETROVIRAL THERAPY MEDICATION TREATMENT EDUCATION ADHERENCE TO ARV THERAPY PCP PROPHYLAXIS MAC PROPHYLAXIS GYNECOLOGY EXAMS TUBERCULOSIS SCREENING (PPD) SYPHILIS SCREENING HEPATITIS C SCREENING VACCINATION SUBSTANCE USE MENTAL HEALTH CARE DENTAL CARE OPHTHALMOLOGICAL CARE LIPID SCREENING BASIC PATIENT EDUCATION

81 National Quality Center (NQC)81 HIVQUAL Indicators – Pediatric ARV THERAPY MANAGEMENT HIV MONITORING (CD4 and VL testing) HIV PEDIATRIC SPECIALIST CARE ANTIRETROVIRAL THERAPY MEDICATION ADHERENCE PCP PROPHYLAXIS MAC PROPHYLAXIS ROUTINE VACCINATIONS NEURODEVELOPMENTAL ASSESSMENTS MULTIDISCIPLINARY CARE PLAN

82 National Quality Center (NQC)82 HIVQUAL Indicators – Case Management Case Management  Complete psychosocial assessment  Patient Knowledge Screening  Treatment Adherence Assessment  Service Care Plan & Coordination of Care  Access and Continuity  Self-Management: Client Participation in Care Planning

83 National Quality Center (NQC)83 Technical Assistance Resources National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY NQC-QI-TA

84 National Quality Center (NQC)84 Technical Assistance Resources National HIVQUAL Project NYSDOH AIDS Institute 90 Church Street—13th Floor New York, NY

85 Funded by HRSA HIV/AIDS Bureau Evaluation

86 National Quality Center (NQC)86 How do you rate this workshop? 1.Very Good 2.Good 3.Okay 4.So, So 5.Not Very Good 10

87 National Quality Center (NQC)87 The workshop kept me interested and engaged? 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

88 National Quality Center (NQC)88 The workshop gave me practical strategies and solutions to use at my HIV program. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

89 National Quality Center (NQC)89 The workshop topic was relevant to me and my HIV program. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

90 National Quality Center (NQC)90 The presenters at this workshop were experts and answered questions effectively. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

91 National Quality Center (NQC)91 The workshop had the right balance of lecture and interactive activities. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

92 National Quality Center (NQC)92 I liked the little remotes…. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree 10

93 Funded by HRSA HIV/AIDS Bureau Thank You :-)

94 Funded by HRSA HIV/AIDS Bureau National Quality Center (NQC)


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