Developing a Quality Management Plan December 2005 Presented by: Roger Chaufournier NQC Consultant Chairman and CEO Patient Infosystems

Attribution The following slides prepared for this presentation were adapted from previous presentations in the Title I Collaborative and contributions were made by Lori DiLorenzo, Barbara Boushon, Ginna Crowe and the Institute for Healthcare Improvement Steal shamelessly and share senselessly….

Overview Theory Legislation Elements of a plan What to look for in a plan

Theories Underpinning Quality Deming’s theory of Profound Knowledge System thinking Variation in daily work Psychology of how people adapt to change Theory of Profound Knowledge Juran’s Trilogy Quality Planning Quality Control Quality Improvement

Juran Trilogy Quality Control Quality Planning Quality Improvement Specification Chronic Waste

Summary: What is it all about? Leaders recognizing how quality aligns with the underlying business case Empowered employees owning work processes and committed to their improvement Accelerated translation of best practices and change concepts to daily work Monitoring, feedback and celebration Change agents rather than victims

QM Legislative Requirements All CARE Act grantees are required to establish quality management programs to: Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections; and Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services

QM Legislative Requirements (cont.) The overall purpose of a quality management program is to ensure that: Services adhere to PHS guidelines and established clinical practice; Program improvement includes supportive services linked to access and adherence to medical care; and Demographic, clinical and utilization data are used to evaluate and address characteristics of the local epidemic.

Key Characteristics of QM Programs A systematic process with identified leadership, accountability and dedicated resources; Use of data and measurable outcomes to determine progress toward relevant, evidence-based benchmarks; Focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement;

Key Characteristics of QM Programs (cont.) Continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement (QI) activities; Data collected is used to feedback into the process to assure that goals are accomplished and they are concurrent with improved outcomes.

Evaluating the QM Plan: Key Elements Quality statement Quality improvement infrastructure Annual quality goals Staff involvement Evaluation As a whole, the QM plan documents how the HIV quality program is structured and what its members hope to accomplish in the coming year. It becomes the foundation for improvement efforts at the project level.

Quality Statement The end toward which all other program activities are directed Example: To provide state-of-the-art HIV quality of care to HIV+ adolescents in the Albany, NY area. To ensure medical care is provided in accordance to the PHS guidelines throughout the Houston EMA. The quality statement describes the purpose of the HIV quality program.

Quality Improvement Infrastructure Leadership Who is ultimately responsible for the HIV program’s quality initiatives? Membership Who will participate in the program’s quality committee? Meeting structure When will the committee meet to plan and assess progress? Internal technical assistance support Indicates how the program is staffed and structured in order to get the work done.

Annual Quality Goals Annual quality goals Performance measurement Endpoints towards which the organization will direct its efforts and resources To reduce patient ‘no-shows’ by 15% Performance measurement Quality of care indicators Kept appointments 1. The true work of an HIV quality program is completed during individual quality improvement projects. 2. QM plan should include information about the yearly projects.

Staff Involvement Quality improvement deployment Individuals or groups designated to implement QI projects Communication How does the organization share information about the quality activities and project results? Education How does the organization provide staff training and learning opportunities?

Evaluation Quality projects Quality improvement management plan Were the projects worthwhile investments? Can the improvements be sustained over time? Quality improvement management plan Does the QM plan provide the vision and organization needed to complete the quality initiatives?

Sustainability Three primary strategies for strengthening program sustainability: Communicating program success Remeasuring performance Building quality into daily work

Communicating Program Success Develop system for employee reward and recognition Champion staff through promotion of success stories Exchange “best practices”-creating a learning organization

Remeasuring Performance Remeasure performance at pre-established intervals Review measurement data regularly Respond to sub par performance in a systematic manner

Building Quality into Daily Work Make QI part of job descriptions Incorporate quality concepts into new employee training Provide ongoing quality training Provide opportunities to participate in QI projects Incorporate best practices 1.Refer participants to the worksheet on sustainability 2. Can use this as you talk with the grantees about sustaining their program to help guide them. 3. These tools can be given to the grantees so that they can perform their own assessment

Summary Well designed program Clear Goals and Vision Infrastructure to Support Improvement System of Measurement Routine Assessment Deployment Methods for Improvement Communication System Alignment