1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. HAB Clinical Performance Measures
Measures focus on clinical services provided to adults & adolescents
Detail sheets outline specific information related to each measure 10

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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. 17

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

19. Donna Yutzy, NQC Consultant
A Brief Into
to Quality Management
Donna Yutzy, NQC Consultant

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

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

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

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

24. 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.

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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.

32. 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.

33. 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.

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

35. 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..

36. 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

37. 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

38. 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)

39. 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

40. 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.

41. 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

42. 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.

43. Quality Improvement Websites
HIV QI publications
Measures
HIVQUAL Software
HIVQUAL Project
Clinical guidelines
Recent news and events
The National HIVQUAL Project’s website is at
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.

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

45. 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

46. 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.

47. 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.

48. 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.

49. NEW !! NQC QI Resources

50. HAB QM TA Manual & FAQ’s

51. QM Program Assessment Tools & QM Plan Checklist

52. 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

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

54. 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

55. 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

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

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