Presentation on theme: "Nanette Brey Magnani and Susan Weigl"— Presentation transcript:
1 Nanette Brey Magnani and Susan Weigl NYS HIVQUAL Workshop: A Guide for Developing Your Quality Management PlansApril17, 2008Nanette Brey Magnani and Susan WeiglNYSDOH AIDS Institute
2 Learning ObjectivesUnderstand the importance and role of a QM Plan to support ongoing QI activitiesUnderstand key elements of a useful written QM PlanCreate a draft of a QM Plan update your own QM PlanKnow where to access resources to help you make your QM Plan a working and helpful, guiding document
3 Agenda 9:00 Welcome. Introductions Review agenda and materials. 9:15 Interactive Presentation: A Guide for DevelopingYour QM Plans.Individual/dyad exercise: After each component of aQM Plan is presented, participants review examplesand highlight aspects of examples that are relevant to them.11:00 Cut and paste highlighted parts into a draft QM Plan.11:30 Large group sharing and next steps.11:50 Feedback and evaluation.12:00 Adjourn.
4 Infrastructure enhances systematic implementation of improvement activities
5 Quality Management Plan PurposeProvides direction of what needs to be accomplished (goals) and how it will be accomplished (action plan) and by whomSets the framework for holding the HIV program and providers accountable for the quality of patient careBasis for self-evaluation for next cycle of improvement
6 Strategic QM Plan (3-5 yrs) Grantee-wide VisionStrategic QM Plan (3-5 yrs)QM PlanAnnual GoalsAction PlanImplementationAnnual Evaluation
7 Format and Components of a QM Plan Section I: Description – Relatively unchanged from year to yearQuality statementInfrastructurePerformance measurementAnnual quality goalsStakeholder participation and developmentEvaluation
8 QM Plan format and components contd. Section II: Annual QI Action Plan– Changes from year to yearPresentation of data and resultsAnnual Improvement Goals/ObjectivesQI ProjectsActivity Timeline
9 How is the QM Plan written? Decide on and systematize your approach to developing/updating your QM PlanAn annual planning meetingA series of shorter meetings that could include piggybacking/using existing QM committee meetingsGetting input (for stakeholders who can’t attend meetings due to time, distance, etc.)
10 (Title of Program) Quality Management Plan Section 1: Description of ____ HIV Quality Management Program
11 I.1. Quality Statement What do we want to be? Brief purpose/mission statement describing the end goal of the HIV quality program to which all other activities are directedAssume an ideal world and ask yourselves, "What do we want to be for our patients and our community?”
12 I.2. Quality Improvement Infrastructure How are we organized?LeadershipWho is responsible for the program-wide quality management initiatives?AccountabilityWho reports to whom re quality; what different committees/groups/meetings have a role in quality and how do they related to each otherQuality Committee(s) StructureMembers? Chairs? Roles? Frequency of meetings? Agendas?CommunicationResourcesResources for the QM program? Staffing?
13 HIV Quality Management Committee An HIV QM Committee oversees the quality management program. The plan usually addresses the following:Committee compositionFrequency and schedule for meetingsPlan for recording agendas, minutes, and other documentationPlan for consumer input
14 Description of QM Committee Responsibilities Selects an improvement process model such as HIVQUAL model and use of PDSAsSets QI prioritiesRecommends new policies or changes in current policy to promote quality careDevelops, monitors, and evaluates overall QM Program, QM Plan and Action Plan, and QI Projects.Provides in put on quality perspective in other planning activities (strategic planning, program development, grants)
15 QM Committee resp. contd Monitors performance measures on applicable PHS standards and on non-clinical standards related to access, linkages, services in support of clinical treatment, and/or other case management performance.Designs new processes, systems and procedures consistent with CQI principles and with the results of QI Projects.Develops a staff development plan to educate staff in quality principles and methods.Maintains internal and external accountability for quality management.
16 Quality Improvement Teams A QI Project Team is charged to make process improvement recommendations in the delivery of care to the HIV QM Committee.Responsibilities:Set improvement goals/objectivesPlan, test and measure changesProvide progress reports to QM CommitteeManage spread of more successful change strategiesEvaluate effort
17 Quality Management Organizational Chart Organization diagram/chart depicts:Relationships: reporting, supervisoryInternal and external linkagesIt helps to see it visually and oftentimes reveals more groups and individuals that have a role or need to be involved in some way. Also, helps to expand understanding of QM Program.
18 Waterbury Hospital Accountability Diagram Internal CommunicationWHICH QM CommitteeHIV Care TeamConsumer AdvisoryGroupRyan WhiteProgram Director
19 Plan for Communication Internal communication (Monthly):The QI program’s progress is on the agenda of the monthly HIV care team and the department of medicine’s monthly meeting. Two consumers are part of the HIV care team. The QI coordinator reports to the HIV care Team on the monthly progress re implementation of the QI work plan, sharing of data on QI projects, and the formation of subcommittees, as needed, during this meeting. The Program director and the CAG representative are present during the HIV care Team meeting.
20 Hospital Accountability Diagram External Communication (annually)WHICH QI CommitteeWaterbury HospQM Committee-HRSA-RW Part A officeRyan WhiteProgram DirectorWaterbury HospExecutiveManagement TeamDept of MedicineDirector
21 I.3. Performance Measurement How will we assess progress?Identify what’s important (critical aspects of care and services provided)Develop ways to measure what’s importantInclude process, outcome and satisfaction measures
22 I.4. Setting Annual Quality Goals How are the annual goals determined?What group/staff?What data is used?What criteria?How often?
23 I.5. Stakeholder Participation and Development How will staff, providers, consumers and other stakeholders be involved in the QM program?Who are they and how can they be involved in the QM Program (internal to the QM Program and external to it)What information do they need and whenProvide opportunities for learning about quality improvement
24 I.6: Evaluation How will we evaluate our overall performance as a program? InfrastructureQI activitiesPerformance MeasuresDid the QM Committee meet and oversee the QM program effectively?Did QI Project Teams meet their goals? Were the right staff on the teams?To what extent were consumers involved in the QM Program?Was the action plan realistic and reflective of the work of the QM Committee, QI Project Teams, & QM Program?To what extent were QI goals achieved? Sustained? Do the same QI Projects need to be extended?Was there the right mix of staff members on the QI Project teams?Were stakeholders informed of and participate in quality activities?Was training provided?Were performance measures reflective of standards of care?Were your results in the expected range?Were results shared with stakeholders?To what extent can quality reports be generated to support the QM Committee’s decisions and program monitoring?You will remember that part of the quality management process is an annual evaluation, the results of which are fed into next year’s quality management plan.The quality management plan needs to state how this evaluation will be done, and how the information the evaluation provides will be used.The evaluation needs to look at three things: Infrastructure effectiveness, QI activities, and performance measures.Was the quality committee effective in improving HIV care and services? Does the quality infrastructure require further adjustment?Were annual quality goals for quality improvement activities met? How effectively did you meet your goals?Did the implementation of the annual work plan go as planned? Did you meet established milestones?Were stakeholders informed about ongoing quality activities? Were staff and providers trained on QI methodologies and tools?Were the measures appropriate to assess the clinical and non-clinical HIV care? Are the results in the expected range of performance?In simple terms:Did our infrastructure work?Did we do what we said we were going to do?Did we get the results we sought, and were we measuring the right things to understand this?QM Plan Elements: Evaluation
25 Section II: Annual QM Program and QI Action Plan How will we implement the QM Plan?1. Presentation of data and resultsAnnual Improvement Goals: programlevel and patient care level3. QI Projects4. Activity Timeline
26 II.1. Presentation of Data and Data Analysis Data and analysis from performance measurement data (patient care)HIVQUAL dataEHR dataPatient satisfaction surveysData and analysis from QM Program evaluationOrganizational quality assessmentFeedback from staff, consumers, QI Project TeamsDisparity dataEpidemiological data
30 II.2. Setting Quality Improvement Goals: Program Level and Patient Care What are the priorities for your quality program?Quality goals are endpoints or conditions towardwhich your Quality Program will direct its efforts andresources.There are generally two levels of improvement goals:QM Program levelPatient care level
31 QM Program LevelBased on your analysis and results of your organizational quality assessment, decide what particular aspects of your QM program can be improved during the next year.Consider the following criteria:What are our resources? Staff? Time?What next steps can we take that is doable?
32 Example: QI Goals for Improving Infrastructure Goal: To increase the effectiveness of the QM Program’s planning and monitoring system.Form a QM CommitteeQM Committee meets more frequently, at least quarterlyWrite an annual QM PlanHold an annual planning session for the QM Committee to discuss results of the performance measurement data and set priorities for improvement
33 Develop your annual QI action plan Examples contd.Develop your annual QI action planEstablish a performance measurement system:select measurestrain staff in data collection and entrycollect datareport results
34 Example: Improving Patient Care Guidelines: When determining priorities try using the following criteria when making your selections:Frequency: How many clients received/did not receive the standard of care/services?Impact: What is the effect on patient health if they do not receive this care/services?Feasibility: Can something be done about this problem with the resources available?
35 Example: QI Goals for Patient Care To increase the annual rate of cervical cancer screening from 43% to 72% by the end of December, 2009.To increase patient retention from 73% to 85% by the end of July, 2009.
36 QM Program Annual Action Plan 3 Goals:QM Program – InfrastructurePerformance Measurement SystemQuality ImprovementQualityManagement Program
43 Part 1: Quality Statement Tips:Be briefBe visionaryInclude internal and external expectationsMake references to external legislative requirements on quality management
44 Part 2: Quality Improvement Infrastructure TipsLimit the length of this section (not every detail is needed)Avoid naming individuals (just job functions)List internal and external stakeholdersList linkages
45 Part 3: Performance Measurement TipsIn developing quality indicators, remember:relevancemeasurabilityaccuracyimprovabilityInclude the process for reviewing and updating indicators (who/when/how)Include strategies to report and disseminate results and findings
46 Part 4: Annual Quality Goals TipsPick only a few measurable and realistic goals annually (not more than 5)Use a broad range of goalsEstablish targets at the beginning of the year for each goal
47 Part 5: Participation of Stakeholders TipsList internal and external stakeholders and their functions/responsibilitiesIncludeClinical providersNon-clinical providersConsumersRepresentatives from agency, such as hospital, network, etc.List proposed training opportunities for stakeholders
48 Part 6: EvaluationTipsDetail when and who is performing the evaluationCompare annual QI goals with year-end resultsUse findings to plan next year’s activities; learn and respond from past performanceRoutinely use organizational assessment tools
49 10 QM Plan TipsDo not reinvent the wheel, use established frameworks to get started‘Steal Shamelessly, Share Senselessly’Size does not matter!80% planning, 20% writingA few visionary annual goals are better than plenty of useful onesBe inclusive, even it takes longer to get your final QM planWhat concrete tips might help when writing a quality management plan? Here are 10 steadfast rules to help guide you.Sample plans are out there. Use the references at the end of this Tutorial to find them, and begin there.As with so many things in quality, make use of what others have done and be willing to share what you’ve accomplished, to help others.It doesn’t matter how long it is. Substance matters more.Think through what you want to do before you start to write. Don’t obsess over the writing, it’s the planning that matters.Use the plan-writing process to push your organization forward.10 QM Plan Rules
50 10 QM Plan Tips (cont.)If you did not update the plan throughout the year, you probably did not look at itA ‘perfect’ plan is never writtenPlans are only as good as their implementationGet started! (Start a first draft. If you have one that hasn’t been updated, take it to your next QM Committee mtg)Involve the people who need to be involved. They will make the plan a living document, rather than something that’s just a hoop to be jumped through.Here’s a tip to make sure your plan stays real – if you’re not using it regularly, haul it out and talk about it. It should be a living guide.Don’t let the perfect be the enemy of the good. If it works for your organization, it’s fine.Plans are only as good as their implementation.To use a popular cliché, just do it! All the planning in the world is for not if you do not take action.10 QM Plan Rules
51 Resources HIVQUAL Workbook NQC Quality Academy Online Tutorial on QM Plans (NQC QM Plan Review ChecklistExample QM Plans from othersHIVQUAL Group Learning GuideMeasuring Clinical Performance: A Guide for HIV Health Care ProvidersHRSA’s Quality Management TA Manual (9-Step Model)
52 THANK YOUMany of these materials can be sent electronically so please contact Nanette or Susan to request them.