Quality Management Plans

1. Quality Management Plans Brazos Valley Council of Governments July 2010

2. The Big Picture: QM Plan Diagram

3. Quality Management Program The term ‘Quality Management Program’ encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (e.g., committee structures, roles for stakeholders, providers and consumers) and quality improvement related activities (performance measurement, quality improvement projects and quality training activities). Key Terms

4. Quality Management Plan A quality management plan is a written document that outlines the HIV quality program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the program. Key Terms

5. Requirements for a Quality Management Program

6. Quality Management Systems require… • The presence of a documented, ongoing quality improvement process (program description and plan of work) • A quality management committee function that includes member roles and responsibilities and documented minutes of each meeting • Significant participation by an M.D. in quality management functions • Evidence of actions to improve quality of care and services, including improvements in accessibility and availability of services • Data analysis in order to identify quality issues

7. Quality Management Systems require… • Satisfaction surveys, follow up on all identified issues identified in the surveys, and documentation of improvement of those issues • The identification of outcomes and efforts at improving them • Identification, monitoring and improvement of adverse outcomes • Corrective action plans for identified quality issues • Program oversight and evidence of management improvements, including revisions to program documentation, policies and procedures, committee actions and other quality initiatives • An annual evaluation of the quality management program

8. QM Plan Components • Quality Statement (Purpose) • Measurable objectives for the QM program • QM Committee Description (member roles, meeting schedule, committee goals and activities) • Activities for identifying quality issues and adverse outcomes • Method for analyzing and correcting quality issues (e.g., PDSA model) • Evaluating your QM program • QM Work plan – a time table with steps needed to implement your QM program

9. Quality Statement A brief mission statement describing the end goal of the HIV quality program to which all other activities are directed

10. QM Program Objectives

11. QM Program Goals/Objectives • What you want to accomplish in your QM Program • The measures could be process or outcome oriented • Process measures are actions that are taken. A process measure could include an assessment of the number of patients with a completed medication adherence screen, the number of client files reviewed, or the number of no-shows to medical appointments. • Outcome measures are the results of care (e.g., the CD4 levels of patients on antiretroviral therapy)

12. QM Committee Membership • Diverse membership representing all areas of the agency • The quality management process should include participation by representatives from agencies involved in the entire continuum of care, including: state and local governments; health, mental health, and social service providers; minority community-based agencies, community-based organizations, and persons with HIV infection. Additionally, these representatives may participate on the QM committee. • A physician is a member and has a significant interface with the QM process; • Documentation of member roles and responsibilities;

13. QM Committee Requirements • Meets at least quarterly; • Documentation of the process used to identify quality issues with actions to analyze and correct them (e.g. Plan-Do-Study-Act); • Documentation of meetings that include attendance, agenda, meeting summary, material/information reviewed, issues/concerns identified and action taken; and • Documentation that shows QM Plan objectives are reviewed and evaluated at least quarterly.

14. Identifying Quality Issues Performance Measurement Data Review

15. Identifying Quality Issues • What are some ways that you identify quality issues? • Performance measurement and data review • Feedback from staff and clients • Client complaints • Chart reviews • Collection of client satisfaction information (via surveys, suggestion box, etc) • Notification from a hospital or other provider of an adverse outcome • Monitoring reports from BVCOG or DSHS

16. Client Satisfaction Survey Process • Details of how the survey is developed, administered and evaluated annually; • Appropriately worded to elicit potential barriers to access, cultural competency, and quality (e.g. general satisfaction, client participation, perceived outcomes, continuity of care, effectiveness or result of service, timeliness of care, customer service/staff skills); and • Documentation of how results are used in the quality improvement process.

17. A documented complaint process that includes: • Effective resolution of issues; • Tracking of trends; and • Description of how results of complaint trends are used in the quality improvement process.

18. Method for analyzing and correcting quality issues (e.g., PDSA model)

19. Evaluating your QM program

20. Evaluation: How Will We Assess the Quality Management Program’s Performance? QI activities Performance measures Infrastructure • Did we improve HIV care and services? • Do we require further adjustment? • Were goals met? • How effectively? • Did work plan go as planned? • Were established milestones hit? • Were stakeholders informed? • Was training provided? • Are results in the expected range? QM Plan Elements: Evaluation

21. Tips for Evaluation

22. Work Plan • Activities planned for the year to implement your program • Includes topics, people assigned, tasks, timeframes, steps taken/steps planned, dates completed • Should be an ongoing work plan that is updated regularly

23. References and Resources • National Quality Center, Quality Academy http://www.nationalqualitycenter.org/QualityAcademy/ • Texas Department of State Health Services, AA Review Tool http://www.dshs.state.tx.us/hivstd/fieldops/EvalTools.shtm • Institute of Medicine, Crossing the Quality Chasm: The IOM Health Care Quality Initiative, http://www.iom.edu/CMS/8089.aspx