Welcome to our Workshop on Quality Improvement :

1
Welcome to our Workshop on Quality
Improvement-)
2
What is Quality Improvement? What are the Quality
Expectations from HAB?
Quality Institute Workshop

• Tuesday, August 29, 800am-930am
• B North 2 Room
• Clemens Steinbock, MBA
• 888-NQC-QI-TA
• cms18_at_health.state.ny.us
• NationalQualityCenter.org

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Agenda

• - Opening Words
• - Overview and Introduction Clemens
• - Quiz Group Activity
• - Principles of Quality Improvement Clemens
• - Scenario Group Activity
• - HRSA Expectations on Quality Clemens
• - Presentations by Grantees Rosa Rodriguez,
  Dr. Jan King
• - QI Resources Clemens
• - Evaluations and Wrap-up

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• How can you make this topic entertaining and
  keep everyone from falling asleep?

5
What are my options?

• Use humor

6
What are my options?

• Use my kids

7
What are my options?

• or
• Use the audience via the Audience Response System

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Quiz
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1) What does CQI stand for?

• Community Quality Initiative
• Case Management Quality Ideas
• Continuous Quality Improvement
• Circular Quantum Invention

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2) Why does Quality Improvement become
increasingly important in health care?

• Quality Improvement has been proven to be
  successful
• Increasing requirements by regulatory agencies
• Increasing accountability by programs for the
  quality of services
• All of the above

11
3) What is the main difference between Quality
Assurance and Quality Improvement?

• Quality Assurance uses mainly a team approach
• Quality Improvement focuses on statistical
  outliers for improvements
• Quality Assurance and Quality Improvement is
  practically the same
• None of the above

12
4) What is the most important principle for
Quality Improvement? Quality Improvement focuses
on

• Individual performers
• Routine measurement of performance
• Training of providers
• Systems issues

13
5) Which of the following statement by HAB is
INCORRECT?

• QM programs need to look beyond clinical services
  to consider both supportive services and outcomes
  
• QM programs assess the extent to which HIV health
  services are consistent with the most recent
  Public Health Service guidelines
• The primary focus of the QM program is on
  performance measurement to assess clinical and
  non-clinical services
• Quality is the degree to which a health or social
  support service meets or exceeds established
  professional standards and user expectations

14
6) HAB describes the following characteristics of
Quality Management Programs. Which ones are
CORRECT?

• Be a systematic process with identified
  leadership, accountability and dedicated
  resources
• Use data and measurable outcomes to determine
  progress toward relevant, evidenced-based
  benchmarks
• Focus on linkages, efficiencies and client
  expectations in addressing outcome improvement
• Ensure that data are fed back into the quality
  improvement process to assure that goals are
  accomplished
• All of the above
• None of the above

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7) The following performance data report is
presented PPD 95, GYN 85, and PCP Prophylaxis
55. You advise the program to continue to
measure

• only PCP Prophylaxis
• GYN and PCP Prophylaxis
• All three indicators

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8) The results of an adherence QI project are
presented after 10 months of work, improving the
rate to 98 and it was kept between 95-100 for
the last 4 months. You advise the program to

• Discontinue routine measurements
• Switch to quarterly measurements
• Keep monthly measurements

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9) Due to the high rate of Mental Health
screening (95), the QI team stopped meeting but
continued to measure the rate monthly. Recently
the score declined. When should the MH QI team to
re-start?

• 90
• 80
• 70

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Couple of more questions
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What is your professional background?

• Clinical Provider (MD, NP, PA)
• Nurse
• Case Manager/Social Worker
• Administrator
• Other

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How do you rate your own quality improvement
knowledge?

• Novice
• Beginner
• Intermediate
• Proficient
• Expert

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How do you rate your HIV Quality Management
Program?

• Not existing
• Beginning
• Sufficient
• Good
• Excellent

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Quality Improvement Principles
Clemens Steinbock, MBA 888-NQC-QI-TA cms18_at_health.
state.ny.us NationalQualityCenter.org
23
Agenda

• What are some quality improvement (QI) guiding
  principles?
• QI models Model for Improvement PDSA, HAB
  9-Step Model, HIVQUAL Model

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QI is not QA
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Three Faces of Quality Improvement
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HABs Working Definition of Quality
Quality of care is the degree to which health
services for individuals and populations increase
the likelihood of desired health outcomes and are
consistent with current professional knowledge.
Institute of Medicine. Medicare A Strategy
for Quality Assurance. Vol. 1. (1990)
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Principles on the Quality Improvement Journey
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Success is achieved through meeting the needs of
those we serve.
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Most problems are found in processes, not in
people. 
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Do not reinvent the wheel Learn from best
practices.
31
Learn through small, incremental changes to
achieve continual improvements.
32
Actions are based upon accurate and measured data.
33
Infrastructure enhances systematic implementation
of improvement activities.
34
Set Priorities and Communicate clearly
35
Survey of 92 Quality Improvement Projects in
Journal of Quality Improvement

• Alemi F, Safaie F, Neuhauser D. A Survey of 92
  Quality Improvement Projects. Journal of
  Quality Improvement 2001, 27(11) 619-632
• 504 days from problem identification to
  completion of first pilot
• 397 days from first team meeting to the end of
  first cycle
• 75 days to describe current situation in
  flowchart
• 62 days for data collection if change was
  improvement

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Model for Improvement

• How can we accelerate change and improvements in
  HIV programs?

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

44
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

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HRSAs 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

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HRSAs 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

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HRSAs 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

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HRSAs 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

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References

• HAB Quality Management Manual, HRSA HIV/AIDS
  Bureau website hab.hrsa.gov/tools/QM

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HIVQUAL Model - Overview

• Goal to assist health care facilities in
  developing a quality infrastructure that supports
  ongoing quality improvement activities.
• Emphasis on sustainability by focusing on the
  structural programmatic and implementation level.
• Practical guide for all HIV programs, regardless
  of their service delivery model, patient
  caseload, or site location.
• Developed by the New York State Department of
  Health AIDS Institute in collaboration with
  HIVQUAL consultants.

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HIVQUAL Model - Overview
Infrastructure
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HIVQUAL Model
HIV Quality Program
Develop and Plan a Quality Improvement Program
Evaluate HIV Quality Improvement Program
Facilitate Implementation of HIV Quality Program
Quality Project
Step 1 Review, Collect and Analyze Data
Step 2 Develop a Project Team Workplan
Step 6 Systematize Change
Step 5 Project Team Evaluates Result(s) with Key
Stakeholders
Step 3 Project Team Investigates the Process
Step 4 Project Team Plans and Tests Change(s)
53
HIVQUAL Model
HIV Quality Program
Develop and Plan a Quality Improvement Program
Evaluate HIV Quality Improvement Program
Facilitate Implementation of HIV Quality Program
Quality Project
Step 1 Review, Collect and Analyze Data
Step 2 Develop a Project Team Workplan
Step 6 Systematize Change
Step 5 Project Team Evaluates Result(s) with Key
Stakeholders
Step 3 Project Team Investigates the Process
Step 4 Project Team Plans and Tests Change(s)
54
References

• Visit the National HIVQUAL Project website
  www.hivqual.org
• HIVQUAL Workbook - Guide for Quality Improvement
  in HIV Care, NYSDOH AIDS Institute Upcoming
  publication

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Scenario Group Exercise
Clemens Steinbock, MBA 888-NQC-QI-TA cms18_at_health.
state.ny.us NationalQualityCenter.org
56
HRSA Quality Expectations
Clemens Steinbock, MBA 888-NQC-QI-TA cms18_at_health.
state.ny.us NationalQualityCenter.org
57
RWCA Reauthorization 2000

• The chief elected official/ grantee shall
  provide for the establishment of a quality
  management program to assess the extent to which
  HIV health services provided to patients under
  the grant are consistent with the most recent
  Public Health Service guidelines for the
  treatment of HIV disease and related
  opportunistic infection, and as applicable, to
  develop strategies for ensuring that such
  services are consistent with the guidelines for
  improvement in the access to and quality of HIV
  health services

58
RWCA Reauthorization 2000

• RWCA grantees are directed to establish quality
  management programs
• assess the extent to which HIV health services
  are consistent with the most recent Public Health
  Service (PHS) guidelines
• develop strategies for ensuring that such
  services are consistent with the guidelines for
  improvement

59
RWCA Reauthorization 2000

• RWCA grantees are directed to establish quality
  management programs
• Development of a comprehensive quality management
  infrastructure, including routine QM Meetings
  with cross-functional representations
• Description of QM Program in a quality plan, with
  a clear indication of responsibilities and
  accountability
• Inclusion and involvement of key stakeholders in
  your quality program
• Designated leaders for quality improvement and
  accountability

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RWCA Reauthorization 2000

• assess the extent to which HIV health services
  are consistent with the most recent Public Health
  Service (PHS) guidelines
• 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
• data are fed back into the organizations quality
  improvement process

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RWCA Reauthorization 2000

• develop strategies for ensuring that such
  services are consistent with the guidelines for
  improvement
• Linking performance data results to quality
  improvement activities
• Establishment of Quality improvement teams with
  cross-functional representation
• Integration of changes into routine program
  activities

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Characteristics of a Quality Management Program -
HAB

• 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

63
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

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Grantee Presentations

• Rosa Rodriguez, Joseph P. Addabbo Family Health
  Center
• Jan King, M.D., M.P.H., Office of AIDS Programs
  and Policy Los Angeles County

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Quality Improvement Resources Websites,
Publications, Technical Assistance
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Websites for Quality Improvement
NationalQualityCenter.org

• HIV measures
• Change ideas
• Best Practices
• Tools/Resources
• Literature
• FAQ

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Website Demo
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Websites for Quality Improvement
www.hivqual.org

• HIV QI publications
• Measures
• Best Practices
• HIVQUAL Project
• Title I/Title II specific QI Materials and
  Indicators

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Websites for Quality Improvement
hab.hrsa.gov

• HRSA QI expectations
• QI Tools
• TA Resources

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Quality Improvement Publications
71
Quality Improvement Publications
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Quality Improvement Publications
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Quality Improvement Publications
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HIVQUAL Software and QM Plan Checklist
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Title III/IV Collaborative and Slide Set
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Upcoming Publications
Quality Improvement Game Guide for HIV Providers
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HIVQUAL Indicators Adult and Adolescent

• 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
• OPHTHALMOLOGICAL CARE
• LIPID SCREENING
• BASIC PATIENT EDUCATION

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HIVQUAL Indicators Pediatric

• PCP PROPHYLAXIS
• MAC PROPHYLAXIS
• ROUTINE VACCINATIONS
• NEURODEVELOPMENTAL ASSESSMENTS
• MULTIDISCIPLINARY CARE PLAN

• ARV THERAPY MANAGEMENT
• HIV MONITORING (CD4 and VL testing)
• HIV PEDIATRIC SPECIALIST CARE
• ANTIRETROVIRAL THERAPY MEDICATION ADHERENCE

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HIVQUAL Indicators Case Management

• 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

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Technical Assistance Resources
National Quality Center (NQC) NYSDOH AIDS
Institute 90 Church Street13th Floor New York,
NY 10007-2919 888-NQC-QI-TA NQCTA_at_health.state.ny.
us
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Technical Assistance Resources
National HIVQUAL Project NYSDOH AIDS
Institute 90 Church Street13th Floor New York,
NY 10007-2919 212 417 4536 cms18_at_health.state.ny.u
s
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Evaluation
83
How do you rate this workshop?

• Very Good
• Good
• Okay
• So, So
• Not Very Good

84
The workshop kept me interested and engaged?

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

85
The workshop gave me practical strategies and
solutions to use at my HIV program.

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

86
The workshop topic was relevant to me and my HIV
program.

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

87
The presenters at this workshop were experts and
answered questions effectively.

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

88
The workshop had the right balance of lecture and
interactive activities.

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

89
I liked the little remotes.

• Strongly Agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

90
Thank You -)
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National Quality Center (NQC)

• 888-NQC-QI-TA
• NationalQualityCenter.org
• NQCTA_at_health.state.ny.us