1. Choosing Quality Measures for HIV Care and Services The Quality Academy Tutorial 8

2. 2 Learning Objectives: You Will Learn About… What an “indicator” is How to select indicators that make sense for your program Steps in defining these indicators The National HIVQUAL Project and the indicators of HIV care it has developed Learning Objectives

3. 3 Tips for Viewing This Presentation Skip to other slides in the presentation Read along with the narrator Search for keywords in the presentation Play, rewind and fast forward Review current slide View full screen Tips for Viewing

4. 4 Key Question What should we be measuring to assess and improve the quality of our HIV care and services? Key Question

5. 5 What is a Quality Indicator? A quality indicator is a tool to assess specific aspects of care and services that are linked to better health outcomes while being consistent with current professional knowledge and meeting client needs. What is an Indicator?

6. 6 Pop Quiz What is an Indicator?

7. 7 Pop Quiz What is an Indicator?

8. 8 Pop Quiz What is an Indicator?

9. 9 Indicators Measure Both… Outcomes The end result The effect on the individual or the population Processes The actions taken to produce the outcome The procedures for achieving the best outcomes What is an Indicator?

10. 10 Examples of Outcomes Include: Patient Health Status Intermediate outcomes like immune & virological status Disability The patient’s own sense of his/her quality of life Hospital and ER visits Patient Satisfaction Public Health Outcomes Retention in Care Access to Care What is an Indicator?

11. 11 Relevant Processes Include… What is an Indicator? Medical careCase management Clinic, program or hospital management State / EMA / network management

12. 12 Process Indicators Examine… Is necessary care provided? Is the care provided necessary? Are services provided in a timely fashion? Are services easily available? Is care provided in the most efficient manner? Is the care provided as intended? Are customers satisfied with how services are provided? Are there patterns of complaints and concerns? What is an Indicator?

13. 13 What Makes a Good Indicator? Relevance Does the indicator affect a lot of people or programs? Does the indicator have a great impact on the programs or patients/clients in your EMA, State, network or clinic? Measurability Can the indicator realistically and efficiently be measured given finite resources? Selecting Indicators

14. 14 What Makes a Good Indicator? (cont.) Accuracy Is the indicator based on accepted guidelines or developed through formal group-decision making methods? Improvability Can the performance rate associated with the indicator realistically be improved given the limitations of your services and population? Selecting Indicators

15. 15 Common HIV-Related Indicators Aspect of HIV CareQuality of Care Indicator HIV monitoringCD4 and/or viral load tests performed every 4 months Antiretroviral therapyAdherence assessment every 4 months TB screeningAnnual PPD testing Prophylaxis of opportunistic infections PCP prophylaxis Gynecologic careAnnual pelvic exam Substance useAnnual substance use assessment Coordination of careAnnual dental exam Selecting Indicators

16. 16Selecting Indicators This slide left intentionally blank

17. 17 Indicators Should Be Clearly Defined This definition includes: Who is eligible to be evaluated? What part of this population should have received the care being measured? (Who should be counted in the denominator?) What part of those who should have received the care did receive the recommended care? (Who should be counted in the numerator?) Defining Indicators

18. 18Defining Indicators

19. 19 How Will You Define Who is Eligible to be Evaluated? Location: all sites, or only some? Gender: men, women, or both? Age: any limits? Client conditions: all HIV-infected clients, or only those with a specific diagnosis? Treatment status? Defining Indicators

20. 20 Example: Eligibility Definition by the National HIVQUAL Project HIV+ ambulatory patients, who have had at least 2 primary care visits in last 12 months; with at least 1 primary care visit in the first 6 months and at least 1 visit in the last 6 months. Defining Indicators

21. 21 Steps in Defining an Indicator 1. Specify the reasonable requirement for care: 2. Define the indicator: Defining Indicators All HIV-positive ambulatory patients with a CD4 count less than 50 cells/mm receive an annual ophthalmology exam % of HIV-positive patients with a CD4 count less than 50 cells/mm within the last year have an annual ophthalmology exam documented in the medical record 3 3

22. 22 Steps in Defining the Indicator (cont.) 3. Set the denominator: 4. Set the numerator: 5. Measurement: Defining Indicators The number of HIV-positive patients with a CD4 count less than 50 cells/mm3 within the last year The number of patients with an annual ophthalmologic exam documented in the medical record Divide the numerator by the denominator to get the performance percentage

23. 23 Example: Pap Test Indicator Defining Indicators IndicatorEligibility % of females 18 and older and sexually active teenagers who received an annual Pap test HIV+ ambulatory patients who have had at least 2 primary care visits in last 12 months

24. 24 Example: Pap Test Indicator (cont.) Defining Indicators DenominatorNumerator Female patients 18 and older or sexually active Number of female patients 18 or older, or sexually active, who received Pap test within the last 12 months and have the test results documented in the medical record

25. 25 Tips For Defining Indicators Base the indicator on guidelines and standards of care when possible Include staff and consumers when developing an indicator to create ownership Be clear in terms of patient / program characteristics (gender, age, patient condition, provider type, etc.) Set specific time-frames in indicator definitions Defining Indicators

26. 26 The National HIVQUAL Project The HIVQUAL Project is a great resource for sample indicators and data collection tools ‘Measuring Clinical Performance’ is a guide for HIV providers to learn more about indicator development and data collection www.HIVQUAL.org HIVQUAL Indicators

27. 27 HIVQUAL Indicator Topics – Adults 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 Ophthalmologic care Lipid screening Basic patient education HIVQUAL Indicators

28. 28 HIVQUAL Indicator Topics – Adolescent Annual Exam Risk Reduction Consumer Involvement Psychosocial Assessment Violence Assessment Sexual Abuse Assessment Sexual Activity Assessment Disclosure Assessment

29. 29 HIVQUAL Indicator Topics – 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 HIVQUAL Indicators

30. 30 HIVQUAL Indicator Topics – 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 HIVQUAL Indicators

31. 31 What is the correct number of eligible patients? Your clinic sees 500 patients at least once a year for any type of visits, including case management. Of these, 360 have had at least two medical visits in the past twelve months. 64 of these patients have had CD4 counts of less than 200. 16 patients received PCP prophylaxis. Test Question HIVQUAL Indicators A) 500 B) 360 C) 64

32. 32 What is the correct denominator for the PCP Prophylaxis Indicator? Your clinic sees 500 patients at least once a year for any type of visits, including case management. Of these, 360 have had at least two medical visits in the past twelve months. 64 of these patients have had CD4 counts of less than 200. 16 patients received PCP prophylaxis. Test Question HIVQUAL Indicators A) 500 B) 360 C) 64

33. 33 What is the correct numerator for the PCP Prophylaxis Indicator? Your clinic sees 500 patients at least once a year for any type of visits, including case management. Of these, 360 have had at least two medical visits in the past twelve months. 64 of these patients have had CD4 counts of less than 200. 16 patients received PCP prophylaxis. Test Question HIVQUAL Indicators A) 500 B) 360 C) 64 D) 16

34. 34 What percentage of eligible patients are receiving proper care? HIVQUAL Indicators Your clinic sees 500 patients at least once a year for any type of visits, including case management. Of these, 360 have had at least two medical visits in the past twelve months. 64 of these patients have had CD4 counts of less than 200. 16 patients received PCP prophylaxis. Test Question A) 72% B) 25% C) 33% D) 20%

35. 35 Other Resources Include: Guidelines: HAB HIV Core Clinical Measures http://hab.hrsa.gov/special/habmeasures.htm http://hab.hrsa.gov/special/habmeasures.htm HIV/AIDS Treatment Information Service www.aidsinfo.nih.govwww.aidsinfo.nih.gov Johns Hopkins AIDS Service www.hopkins-aids.eduwww.hopkins-aids.edu Indicator definitions: New York State Department of Health AIDS Institute www.HivGuidelines.org www.HivGuidelines.org National Quality Center NationalQualityCenter.orgNationalQualityCenter.org Agency for Healthcare Research and Quality www.qualityindicators.ahrq.gov www.qualityindicators.ahrq.gov Resources

36. 36 Link Performance Data to Quality Improvement Activities HIVQUAL Indicators

37. 37 Key Points An indicator is tool to measure of a part of your program’s work that contributes to care or services that meet client needs Good indicators are relevant to your program’s work, measurable, based on established guidelines or consensus, and relate to something that can, in fact, be improved Each indicator needs to be clearly defined Good examples exist: use them! Key Points

38. 38 Resources More detailed information about the HIVQUAL Project can be accessed at: http://www.HivGuidelines.orghttp://www.HivGuidelines.org Measuring Clinical Performance: A Guide for HIV Health Care Providers. A publication of the AIDS Education Training Centers and the New York State Department of Health, AIDS Institute, 2006. The guide can be downloaded at: http://nationalqualitycenter.org/index.cfm/6127/1 3908 http://nationalqualitycenter.org/index.cfm/6127/1 3908 Resources

39. 39 Related Tutorials To learn more about measurement, study Tutorial 7 To learn more about data collection, study Tutorial 9 To learn more about data and improvement projects, study Tutorial 10 Related Tutorials

40. 40 The Quality Academy For further information, contact: National Quality Center New York State Dept. of Health 90 Church Street, 13 th floor New York, NY 10007-2919 Work: 212.417.4730 Fax: 212.417.4684 Email: Info@NationalQualityCenter.org Info@NationalQualityCenter.org Or visit us online at NationalQualityCenter.org NationalQualityCenter.org In Closing