Quality Management 101 and HRSA/HAB Expectations Welcome to the NQC National TA Conference Call: Quality Management 101 and HRSA/HAB Expectations January 8, 2009 Presenters: Tracy Matthews, HAB; Donna Yutzy, NQC Consultant; Meera Vohra, NQC

Presentation Overview HAB’s Quality Expectations Definitions Key characteristics of QM Programs HRSA’s 9-step Model to Quality Types of measures/sample measures The Model for Improvement QM Resources

HRSA/HAB Quality Expectations Tracy Matthews Acting Chief Clinical Advisor Division of Community Based Programs TMatthews@hrsa.gov 3

Ryan White HIV/AIDS Treatment Modernization Act 0f 2006 All RWTMA grantees are required to establish clinical 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 4

Ryan White HIV/AIDS Treatment Modernization Act 0f 2006 “RWTMA 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 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 5

Ryan White HIV/AIDS Treatment Modernization Act 0f 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 6

Ryan White HIV/AIDS Treatment Modernization Act 0f 2006 “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV services…” which includes: Linking performance data results to quality improvement activities Establishment of Quality improvement teams with cross-functional representation Integration of changes into routine program activities 7

Key Characteristics of a Quality Management Program Patient-centeredness is a fundamental focus of quality care and supports 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 8

Key Characteristics of a Quality Management Program (cont.) 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 9

HAB Clinical Performance Measures http://hab.hrsa.gov/special/habmeasures.htm Measures focus on clinical services provided to adults & adolescents Detail sheets outline specific information related to each measure 10

HAB Clinical Performance Measures: Group 1 Group 1 represents the 5 core clinical performance measures deemed critical for HIV programs to monitor Released 12/07 Core clinical performance measures can be used by all grantees Bring up the updated list of measures and make downloadable from the webex.

HAB Clinical Performance Measures: Group 2 Group 2 has 9 clinical performance measures Measures reflect important aspect of care that impacts HIV-related morbidity and focuses on treatment decisions that affect a sizable population Released 8/08

HAB Clinical Performance Measures: Group 3 Group 3 includes 11 clinical performance measures The measures focus on similar aspects of care captured in measures listed in Groups 1 & 2 To be released in final form early Spring 2009

HAB Clinical Performance Measures Grantees are encouraged to include the 5 core clinical performance measures in their quality management plan Grantees are not required to submit performance measurement data to HAB FAQs developed as a companion guide and is updated with each release of measures and annually http://hab.hrsa.gov/special/habmeasures.htm

Alignment with Other Measures HAB performance measures are specific to the Ryan White HIV/AIDS Program Alignment with other measures such as those developed by OPR, NCQA, IDSA, and AMA HIVQUAL measures are similar to the HAB clinical performance measures HIVQUAL sites are encouraged to continue to submit HIVQUAL data 15

HAB Performance Measures: Next Steps Performance measures related to case management, oral health, ADAP and systems level FAQs will be updated as new measures are released CAREWare Performance Measurement Module 16

HAB Performance Measures: Next Steps Any comments or feedback on the utilization of the measures is encouraged. Any recommendations or suggestions for additional measures is welcome. HIVMeasures@hrsa.gov 17

Questions? Thank you! Tracy Matthews Acting Chief Clinical Advisor Division of Community Based Programs TMatthews@hrsa.gov 18

Donna Yutzy, NQC Consultant A Brief Into to Quality Management Donna Yutzy, NQC Consultant dyutzy@aol.com

Definitions Quality = degree to which a health or social service meets or exceeds established professional standards and user expectations.

Definitions Quality Assurance (QA) = a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards.

Definitions Quality Improvement (QI) = refers to activities aimed at improving performance.

Definitions Continuous Quality Improvement (CQI) = describes the ongoing monitoring, evaluation and improvement processes.

Definitions Indicator = measure used to determine, over time, an organization’s performance of a particular element of care. The indicator may measure function, process or outcome.

Definitions Outcome = Benefits or other results (positive or negative) for clients that may occur during or after their participation in a program. Outcomes may be client-level or system-level.

HAB’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 Available at hab.hrsa.gov/tools/QM

HAB’s 9-Step Model to Quality Commit Leadership & Supportive Organizational Structure Establish support of program leadership for Quality Management Delineate specific QM responsibilities of staff 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 Determine Performance Measures & Collect Data Based on QM priorities, develop/adopt indicators to measure performance Determine method of data collection and collect data

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

HAB’s 9-Step Model to Quality 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. Re-measurement Re-measure indicator after change has been implemented. Determine need for and/or level of re-measurement on an ongoing basis. Celebrate Success Communicate results of the project to all levels of the organization Congratulate team in public forum

Developing Measures The QM Plan should be the vehicle for examining how well your agency is doing in executing your program’s priorities and strategies. The focus is not on the performance of individuals or individuals agencies/contractors, but rather focuses on how the systems are working to improve HIV care.

Developing Measures The QM Committee should develop a core set of measures that provide a snapshot of the overall quality of care provided by your program. When possible, it’s smart to start with measures that are already being collected and used in the system. Recommended to include HAB core clinical indicators.

Types of Measures Outcome measures are the voice of the customer. Outcome measures reflect the impact of our work on the care provided to our clients. Examples: incidence of disease rates, functional status indicators, mortality & morbidity rates, client/care team satisfaction rates, or cost of care delivered.

Types of Measures Process measures are the voice of the system. Process measures tell us whether parts or steps in the system are working as planned. Examples: Waiting time for appointments, no show rates, percent of clients with self-management goals in place, the number of clients organized by acuity level in case management, length of time to process ADAP applications or ADAP re-certification rates.

How can we accelerate change and improvements in HIV programs? Model for Improvement How can we accelerate change and improvements in HIV programs?

What change can we make that will result in improvement? Model for Improvement 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? So what is the third question? The changes that you make should align with your aim and measures… Where do they come from ? IHI change packages… chanes with a pedigree… have a high degree of belief they willwork .. Have worked .. Ideas in the op doc.. Op Doc.. Each other..

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

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

Tips for PDSA Cycles Use shorter test cycles to accelerate rate of improvement (“What can you test by next Tuesday?”) Collect just enough data, not perfect data Scale down size of test (# of patients, clinics) Test first in ‘safe zones’ Formulate question and predict results Toyota: 80 improvements per employee; US hospital: 0.5 improvement per employee electronic interchange of improvement learning (IHI-Extranet; Kaiser Permanente-Learning Link; VHA Improvement Exchange)

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

Building Quality into Daily Work Make QM part of contracts with providers. Make QI part of job descriptions. Incorporate quality concepts into new employee training. Provide ongoing quality training to internal staff and to contractors. Provide opportunities for internal staff and contractors to participate in QI projects. Incorporate best practices into your service delivery.

Quality Improvement Resources: Websites, Publications, Technical Assistance 86,408 PLWA – reported in the 8 states At least 43,000 PLHIV – estimated TOTAL POTENTIAL IMPACT: IMPROVING THE QUALITY OF CARE FOR 129,000 PLHIV/AIDS -- >10% of PLHIV/AIDS in United States Meera Vohra, NQC Meera@NationalQualityCenter.org

Quality Improvement Websites NationalQualityCenter.org HIV measures Change ideas Best practices Tools/resources Literature FAQ Each of these organizations has a web site, which we recommend you explore. First, NQC’s web site is at nationalqualitycenter.org. This web site is designed to provide cutting-edge information on measures of quality in HIV care, ideas for changes that will result in improvement, best practices in providing HIV care and services, tools and other resources to strengthen quality management programs and quality improvement work, recent literature and answers to frequently asked questions. More than 170 different tools are currently posted on the website. The NQC website contains links to the other sites mentioned in this Tutorial, so don’t worry if you don’t catch all the names.

Quality Improvement Websites www.HIVQUAL.org HIV QI publications Measures HIVQUAL Software HIVQUAL Project Clinical guidelines Recent news and events The National HIVQUAL Project’s website is at www.HIVQUAL.org. Managed in concert with Johns Hopkins University, the website provides access to a wide range of publications about HIV care and quality improvement, information about measures of quality for HIV care, and more details about the HIVQUAL Project and how to become involved. The site also details clinical practice guidelines and links to articles about recent developments in the clinical care of people with HIV and AIDS.

Websites for Quality Improvement hab.hrsa.gov HRSA QI expectations QI Tools TA Resources

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

Quality Improvement Publications There are many publications available to help your organization in its quality improvement work. “Measuring Clinical Performance: A Guide for HIV Health Care Providers” is a publication we will mention often during The Quality Academy. The New York State Department of Health AIDS Institute developed this guide that includes a step-by-step process for measuring clinical performance with the goal of improving quality of care. This guide, and other quality improvement resources can be downloaded when clicking on the documents on your screen. A second, valuable New York State Department of Health AIDS Institute publication is “Patient Satisfaction Survey for HIV Ambulatory Care.” Patient satisfaction is an important element of the quality of care, but good surveys are difficult to develop. This is believed to be the first HIV-specific validated satisfaction survey with 5 modules, including case management, women’s health, substance use, etc. This tool is also available in Spanish.

Quality Improvement Publications Here are two resources for those who are training others on the topic of quality improvement in HIV care. The HIVQUAL Project’s Group Learning Guide contains instructions for 23 interactive exercises that teach the key points of quality improvement, gleaned from workshops held with HIV providers in the HIVQUAL Project. The Group Learning Guide includes facilitator notes, interactive group exercises, presentation slides and answer keys. The NQC Game Guide contains 20 creative, engaging and interactive exercises that teach the key principles of quality improvement in HIV care. Use these exercises to help create enthusiasm for quality improvement work in your organization. The Guide includes facilitator notes and practical tips on how to apply “lessons learned” in HIV care.

Quality Improvement Publications As we’ve mentioned in other Tutorials, it is vitally important to also involve consumers in your quality improvement work. Here are two resources for empowering consumers and involving them in quality improvement activities. On the left, you see “Making Sure Your HIV Care is the Best it Can Be,” a guide for facilitators to train consumers in how to understand HIV clinical care performance data and more importantly how consumers can become empowered to partner with health care providers. And on your right, ‘A Guide to Consumer Involvement’ details strategies and practices how to best solicit consumer feedback and involve consumers in quality improvement related activities. The Guide also includes lessons learned how to best identify and overcome barriers to consumer involvement.

NEW !! NQC QI Resources

HAB QM TA Manual & FAQ’s

QM Program Assessment Tools & QM Plan Checklist

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

QI Teaching Resources Teaching Quality Improvement Fundamentals Teaching Performance Measurement Teaching QM Infrastructure Teaching Quality Improvement Activities Teaching Patients on Quality

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

QM Training-of-Trainers (TOT) 3-day intensive training to develop capacity to train others in QM Significant Pre-work required Must lead at least 3 trainings within 120 days of completing the TOT

On-site TA for QM On-site, individualized technical assistance is available, free of cost from: National Quality Center (All Parts) www.NationalQualityCenter.org National HIVQUAL Project (Part C & D only) www.HIVQUAL.org

National Quality Center (NQC) 888-NQC-QI-TA Info@NationalQualityCenter.org NationalQualityCenter.org