NQC National TA Call Developing QM Infrastructure Examples

NQC National TA Call: Developing QM Infrastructure: Examples and Solutions from the Field March 13, 2008, 3 – 4 pm EST Nanette Brey Magnani, Ed. D, NQC Quality Consultant Hollie Malamud-Price, MPH, Part D Program Coordinator, Michigan Department of Community Health Rosemary Donnelly, MSN, APRN, HIV Nurse Consultant, HIV Section, Georgia Division of Public Health 1 1 National Quality Center (NQC)

Agenda • Purpose and components of a written Quality Management Plan • Purpose and tips for Quality Management Committees • Challenges and solutions related to QM Plans and QM Committees 2 National Quality Center (NQC)

Infrastructure enhances systematic implementation of improvement activities Infrastructure 3 National Quality Center (NQC)

Quality Management Plan Purpose § Provides direction of what needs to be accomplished (goals) and how it will be accomplished (workplan) § Clear indication of who is responsible § Sets the framework for holding grantee and providers accountable for its accomplishments § Basis for self-evaluation for next cycle of improvement 4 National Quality Center (NQC)

Grantee-wide Vision Strategic QM Plan (3 -5 yrs) QM Plan (annual) Annual Goals Workplan Implementation Annual Evaluation 5 National Quality Center (NQC)

Key Components of an Annual QM Plan 1. 2. 3. 4. 5. 6. 7. 8. 6 Quality Statement Infrastructure Performance Measurement – 5/8/08 TA Call Annual Quality Goals – integrated into 7/10/08 TA Call Stakeholder Development – integrated into series Consumer Involvement – 9/10/08 TA Call Evaluation Workplan National Quality Center (NQC)

Part 1: Quality Statement What do we want to be? • Describe the end goal of the HIV quality program to which all other activities are directed • Assume an ideal world and ask yourselves, "What do we want to be for our patients and our community? “ 7 National Quality Center (NQC)

Quality Statement Example The Positive Health Care program provides comprehensive HIV primary care and prevention services to persons in Southern Maine. Positive Health Care is committed to the delivery of high quality care to our patients. We strive to continuously improve the quality of care consistent with recognized national standards, current research, and Ryan White Care Act guidelines. 8 National Quality Center (NQC)

Part 2: Quality Improvement Infrastructure How are we organized? Leadership § Who is responsible for the grantee-wide quality improvement initiatives? Accountability § Who is responsible for making changes? § How does it get reported? § How are consumers involved? Other major stakeholders? 9 National Quality Center (NQC)

Part 2: Quality Improvement Infrastructure Quality Committee Structure § Membership § Leadership § Charge, plan, reporting Resources § Budget § Staffing § Time and assistance from MIS § Volunteers 10 National Quality Center (NQC)

Part 2: Quality Improvement Infrastructure • List internal and external linkages • Draw an organization diagram/chart to depict how HIV Quality Program relates to other committees, groups, departments in organization, sub contracting agencies, other RW programs. 11 National Quality Center (NQC)

Example: Georgia – QM Committees QM Core Team Sub committees § Performance Measures § Case Management Coordination with Other Statewide QI/QA Activities § across Ryan White Programs § within DPH § with ADAP § Communication with Key Stakeholders 12 National Quality Center (NQC)

MDCH – Ryan White Part D Quality Management System Part D MDCH Program Coordinator Ryan White Cross Part Quality Committee Part D Executive Committee Quality Mgmt Committee Members & Representatives from Funded Agencies (Meets Quarterly) Part D Sub-Contractor Quality Mgmt Meetings/Trainings DMC Horizons PIDC UHC Quarterly Evaluation Mtg Bi-Monthly Mgmt Team Mtgs APM Quarterly QM Committee Mtg CHM QI Group Project Challenge Monthly Team Meetings, Includes QI Immunology Clinic Bi-Monthly Mgmt Team Mtgs VNA Care Services Monthly Team Meetings Wellness Monthly Quality Committee Meeting Weekly Case Mgt Mtgs DHWP CARES Quarterly Quality Mgt Team Meetings Monthly Mgmt Team Mtgs Bi-Monthly Case Mgr Mtgs **All subcontracted agencies minimally participate in contractual Quality Improvement activities. 13 National Quality Center (NQC)

Part 3: Performance Measurement How will we assess progress? • Identify and quantify the critical aspects of care and services provided in your HIV program • Develop indicators and measure progress 14 National Quality Center (NQC)

Example: Michigan Part D Quality indicators are chosen for review from the following areas: • Clinical/medical primary care • Coordination of services • Case management • Outreach/peer support/advocacy • Continuity of care • Psycho social and mental health services 15 National Quality Center (NQC)

Part 4: Annual Quality Goals What are the priorities for the quality program? • Quality goals are endpoints or conditions toward which a quality program directs its efforts and resources 16 National Quality Center (NQC)

Example: Michigan Part D Program Function/Performance Measure Goals for 2008 Documentation of a pap smear (statewide indicator) 75% of eligible female patients will have UHC, PIDC, documented test results and/or copies Horizon’s Project from an outside provider. # of women with annual Pap smears/# of women with 1 medical visit in the 12 month period. Documentation of case management care (service) plans (statewide indicator) 90% of clients will have a care plan documented and updated at least every six months. Horizons, APM, CARES, VNA, Wellness Clients with identified needs will have documentation of referrals. Increase from 51% to 75% the number of Part D eligible client charts which documented coordination of services among 2 disciplines. UHC 17 Program Responsible National Quality Center (NQC)

Example: Georgia, Part B • Percent of HIV-infected clients with AIDS who were prescribed HAART. (Goal 90%) • Percent of HIV-infected clients on HAART with HIV viral loads < 75 copies/m. L. (Goal 50%) • Percent of ADAP applicants approved or denied for ADAP enrollment within two weeks of the ADAP receiving a complete application. (Goal 95%) 18 National Quality Center (NQC)

Georgia example cont’d. • Percent of ADAP enrollees recertified for ADAP eligibility criteria at least annually. (Goal 95%) • RW funded providers will implement cont. quality improvement mechanisms within their own agency including written QM Plans and a report of most recent CQI activities and results. 19 National Quality Center (NQC)

Part 5: Stakeholder Development • Assess education needs of stakeholders • Provide training opportunities for staff, providers and other stakeholders 20 National Quality Center (NQC)

Example: Michigan Part D Strategy Combining Provider Training with Quarterly Meetings Combine provider training with quarterly meetings § participants are staff responsible for quality improvement projects § Agenda includes • Program updates • Discussion of performance measurements and goals • Training topics: QI projects, PDSAs, measuring PDSAs, QI tools (not all in one session) • Peer exchange of what works 21 National Quality Center (NQC)

Part 6: Consumer Involvement How will consumers be involved in the QM Program? • Engage consumers through various mechanisms with the intent of increasing their participation over time. Moderate Participation Surveys Focus groups Individual interviews 22 Higher Participation Consumer Advisory Boards Representation on Quality Committees Representation at Planning Meetings National Quality Center (NQC)

Part 7: Evaluation How will we evaluate our overall performance as a program? Evaluation efforts should include: • Review of performance data • Review of QI Projects conducted over the year • Effectiveness of QM Plan 23 National Quality Center (NQC)

Example: Georgia, Part B - Evaluation Self-Assessment • QM Program Assessment Tool (NQC) • Checklist for Review of QM Plan (NQC) to review Plan • Rating of Completeness of strategies Site Visits • Conducted annually • Review of subgrantee QM plans and QI activities and progress on case management standards and performance indicators DPH • Findings reported annually • Revised QM Plan for approval 24 National Quality Center (NQC)

Part 8: Annual Workplan How will we implement the QM Plan? • The workplan should include: § List of key activities § Identification of who is responsible for completing or overseeing the completion of activities § When the activities are to be carried out and completed during the year 25 National Quality Center (NQC)

Example: Georgia, Part B – Annual QM Timeline Ryan White Program Part B Final Progress Report Due Implement Revised QM Plan and Workplan April May June July QM Core Team Mtg. Review Progress & Update Workplan Finalize Previous FY QM Progress Report 26 August Ryan White Program Part B Grant Due Mid-Year Progress Report Due September October QM Core Team Mtg. Review Progress & Update Workplan Draft Interim Progress Report November December QM Core Team Mtg. Review Progress & Update Workplan Plan for Next FY Revise QM Plan & Workplan January February Obtain Internal Approval for Plan March QM Core Team Mtg. Review Progress Review/Approve Revised QM Plan and Workplan National Quality Center (NQC)

Issues Identified by Grantees Quality Management Plans 27 National Quality Center (NQC)

BIG Questions: Who writes the QM Plan? Who needs to be involved? • No QM Plan • Difficulties with QM Plan Implementation § Setting goals § Developing standards of care, quality indicators and § § § 28 measures Not setting priorities Inexperience of members (“it can be frustrating”) Not a realistic plan No buy-in Time consuming Conflicting personalities and who is in charge National Quality Center (NQC)

Possible Solutions Inexperience – ask for training (NQC Quality Academy, NQC TA Request, join HIVQUAL Project for Parts C & D…); ask a peer grantee for assistance Conflicting personalities – bring in someone not involved, training can help (NQC) Time consuming – don’t reinvent the wheel, check NQC website for examples of other QM Plans Not a realistic plan; no buy-in – Use a participatory planning process 29 National Quality Center (NQC)

Tips for Who is Involved, How and When? Decide on your approach to developing/updating your QM Plan § An annual planning meeting § A series of shorter meetings that could include piggybacking/using existing QM committee meetings § Getting input (for stakeholders who can’t attend meetings due to time, distance, etc. ) 30 National Quality Center (NQC)

Tips for Who is Involved, How and When? Systematize timing for QM Plan updates § Annually § Bi-annual updates 31 National Quality Center (NQC)

Quality Management Committees Purpose § Strategic planning § Facilitating innovation and change § Providing guidance § Establishing a QI culture § Allocating resources 32 National Quality Center (NQC)

Tips for Effective QM Committees • • • 33 Start with a small group of critical individuals Cross- functional representation Include consumers If applicable, include cross-Part reps Clarify purpose/responsibilities of Committee Train members on QI methodologies Identify a Chairperson to moderate Develop a meeting schedule Set agenda and take minutes to document key decisions Communicate Committee activities/decisions with staff, providers, and other stakeholders National Quality Center (NQC)

Issues Identified by Grantees Quality Management Committees 34 National Quality Center (NQC)

Issues regarding QM Committees • • • 35 Too many sub committees, fractured work Disinterested in QM Lack of QM knowledge Infrequent and inconsistent attendance Staff turnover Ineffective relationship between Committee Chair and Quality Manager National Quality Center (NQC)

Issues regarding QM Committees • Membership turnover – how to get new people up to speed. This places a greater burden on fewer members to get the work done • Membership is voluntary and secondary to members’ fulltime jobs • Competing demands between Parts A, B, and setting up an All Parts QM Committee • Not understanding what the QM Committee needs to do and how to do it 36 National Quality Center (NQC)

Making Your QM Committee a Success: Ideas from Fellow Grantees • Oakland meets quarterly instead of monthly to keep up attendance • San Juan changed the meeting times to coincide with Planning Council meetings • To keep members interested and develop their knowledge and skills, San Juan and Oakland incorporate training and guest speakers at meetings; others trained members in how to develop indicators and measures • Phoenix schedules meetings in advance so members have meetings on their schedules; they want to increase their meetings to quarterly; reviewing the QM plan annually helps members see what was accomplished 37 National Quality Center (NQC)

Making Your QM Committee a Success: Ideas from Fellow Grantees • Dallas requires their medical providers to have an active role on its Performance Improvement Committee and other service providers depending on the issue being discussed • Ohio found that once staff were trained in QM they were interested in participating in the committee • Norfolk saw interest in QM rise following an assessment activity when providers said they were enthused about doing QI Projects 38 National Quality Center (NQC)

Resource: NQC Quality Management Plan Checklist for the review of an HIV specific Quality Management Plan www. National. Quality. Center. org 39 National Quality Center (NQC)

Resource: NQC QM Program Assessment Tools (Part- Specific) Standardized Assessment Tools to assess the key elements of your QM Program www. National. Quality. Center. org 40 National Quality Center (NQC)

NQC QM Infrastructure Resources NQC Quality Academy: www. nationalqualitycenter. org/Quality. Academy • Tutorial 5: Quality Management Plan • Tutorial 6: Quality Management Infrastructure Previous NQC TA Calls: www. nationalqualitycenter. org • April 12, 2007: Developing QM Infrastructure for Part C&D • March 8, 2007: Developing QM Infrastructure for Part A&B • June 5, 2006: QM Plans for Part C&D (with sample QM Plans) • December 15. 2005: QM Plans for Part A&B (with sample QM Plans) 2006 RWCA AGM Workshop: • Strengthen Your Quality Infrastructure by Developing a Sound QM Plan (Sample QM Plans: Missouri Part B, Oakland EMA) 41 National Quality Center (NQC)

Today’s Grantee Presenters: Hollie Malamud-Price, M. P. H. , RWTMA Part D Program Coordinator Michigan Department of Community Health, 3056 W. Grand Blvd. , Suite 3 -150 Detroit, MI 48202; (p) 313. 456. 4362; (f) 313. 456. 4427 E-mail: malamudh@michigan. gov Rosemary Donnelly, MSN, APRN-BC, ACRN, PHSO Nurse Consultant HIV Section, Georgia Division of Public Health, 2 Peachtree Street, NW, Ste 12 -264 Atlanta, GA 30303; (p) 404. 463. 0415; (f) 404. 657. 3119; E-mail: rdonnelly@dhr. state. ga. us 42 National Quality Center (NQC)

National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street— 13 th Floor New York, NY 10007 -2919 888 -NQC-QI-TA Info@National. Quality. Center. org 43 43 National Quality Center (NQC)