Sherry Martin, NQC Coach, Claudia Medina, NQC Fellow, Julia Schlueter, NQC Fellow

1. Quality Institute #2Session 2: Guidance to Creating a Culture for Quality: How to Work with your Subcontractors on Quality Management Sherry Martin, NQC Coach, Claudia Medina, NQC Fellow, Julia Schlueter, NQC Fellow Thursday, November 29, 2012 8 am to 9:30 am Delaware A RWA-0248

2. NQC and Quality Workshops at 2012 AGM

3. NQC at 2012 AGM • Networking Opportunities - Interact with your peers… • Tue, Nov 27 12pm: HIVQUAL Regional Group– Thurgood Marshall Ballroom West • Wed, Nov 28 12pm: in+care Campaign - Thurgood Marshall Ballroom South • NQC Exhibit Booth - Stop by our booth… • NQC Office Hours - Meet one of our NQC coaches...

4. Session Agenda • Key success factors to achieve high performance results • Successful strategies used to engage subcontractors- Part A, B, C and D agencies • Group exercise – identification of measures on which to focus improvement initiatives; challenges and potential solutions • Key learning points – group reports

5. Learning Objectives • Describe the importance of aligning subcontractor agency quality management plans and improvement initiatives with those of the grantee and/or the National AIDS Strategy • Identify the critical few opportunities for improvement for subcontractors based upon results of measures and national information and goals • Describe methods used successfully to ensure accurate, consistent and timely data on key measures and subcontractor engagement in the quality program • Implement improvement initiatives across the network to encourage a unified sustained approach

6. Key Success Factors to Achieve High Performing Results • Alignment of goals, measures, improvement initiatives to achieve mission and national strategy goals • Accurate and consistent data collection methods and definitions • Contractual agreements that define quality program expectations • Strong guidance and tools – service plans, education forums, one-on-one data assistance

7. The Mission/Purpose StatementThe Focus of the Quality Program • Describes the core function of the network and delineates the scope of services • May describe the vision for the future • Directs and prioritizes network goals and action plans • Aligns the organization with subunits • Drives all strategic decisions

8. Mission Statement Examples • Our mission is to develop and maintain a state-wide quality program that improves patient health outcomes for individuals living with HIV. The vision is to become trend-setters in quality health care initiatives. • The (network name) Network’s mission is to: provide comprehensive family-centered health care and support services for women, youth, children and families infected with or affected by HIV in (State/Region/City).

9. Alignment – Key Success Factor All stakeholders should understand and agree to the tenets of the Mission, Vision and/or Purpose Statements • Rethink and articulate the mission/vision/purpose occasionally with all stakeholders • Align with current national treatment information, including the National AIDS Strategy • Communicate in multiple ways, frequently • Align with reward, recognition and accountability programs

10. Alignment – Key Success Factor Quality Infrastructure, Plans and Contracts • Agency Quality Committee includes leaders from each subcontractor agency • Agency Quality Plan (Purpose) is endorsed by all agencies and reviewed annually • Subcontractor Quality Plans include relationship with the agency, common goals and methods • Contracts with subcontractors describe quality program expectations

11. Alignment – Key Success FactorAccurate and Consistent Data • Measure definitions must be consistently applied at all sites; this requires validation • Sampling methods must be consistent • Source data must be accurate • Data collection must be frequent enough to provide usable information • Results should be arrayed against time (run or control charts) for analysis

12. Alignment – Key Success FactorIdentification of Measures to Improve • Identify measures to improve performance on the basis of results and current national and local information, including the National AIDS Strategy • Prioritize the selection on the basis of those that will progress the network to their mission • Include all subcontractor representatives in the selection • Define data collection logistics together – data sources, sampling methods, definitions, frequency of reporting and formatting

13. Alignment – Key Success FactorImprovement Initiative Direction and Guidance • All subcontractors identify an agency measure on which to focus improvement work based upon their results • Subcontractors use quality methods to identify opportunities to improve the network measure and to conduct an improvement project • Network provides help with data collection and submission and quality improvement methods • Progress on measures are reviewed regularly • Improvement strategies are shared formally and regularly • “Home runs” are celebrated

14. Measures to Evaluate Mission/Purpose Progress Our mission is to develop and maintain a network-wide quality program that improves patient health outcomes for those individuals living with HIV. The vision is to become trend-setters in quality health care initiatives and family centered care. What are possible measures that might be selected to achieve this vision?

15. Potential Measures for Improvement Focus • Patient outcome (and surrogate) measures • Mortality • Viral Load Suppression – ( National AIDS Strategy) • Process measures • Retention- in- Care; Medical Visits – ( National AIDS Strategy) • New patients • Results are in the “trendsetter class” • Best practice clinics

16. Measures to Evaluate Mission/Purpose Progress The (network name) Network’s mission is to: provide comprehensive family-centered health care and support services for women, youth, children and families infected with or affected by HIV in (State/Region/City).

17. Potential Measures to Evaluate Mission • Patient HIV outcome measures segregated by women, youth, children • Primary care measures – diabetic, asthma, cardiac • Family engagement measures identified through various listening posts • Surveys • Focus groups

18. Idaho HIV Care Programs A low incident state’s experience with quality management programs. BeBe Thompson RW Part B/ADAP Coordinator Idaho Dept. of Health and Welfare

19. The Challenge HIV/AIDS Treatment Cascade.

20. A LITTLE BACKGROUND Idaho HIV Care: • Low incidence state (1,254 PLWH/A, 12/31/2010) • Ryan White Part B and Part C’s only • Staff and funding limited • All state, clinic and contractor staff have many roles • RWPB funds HIV monitoring labs and medical case management • Part C’s provide nearly all clinical and primary care for Idaho’s HIV positive Challenge: • How do we align our quality management activities to the National HIV/AIDSStrategy? • Statewide measures encompassing all clinics and contractors

21. Part B and Part C Interactions • Different data collection and measure exclusions • HIV Qual versus HAB Performance Measures • Choose one and stick to it for statewide measures Focus on the strategy’s three primary goals: • Reducing the number of people who become infected with HIV • Increasing access to care and improving health outcomes for people living with HIV • Reducing HIV-related health disparities

22. NQC Consultant and Idaho QM Committee • Move away from categorizing in clinical and non-clinical measures • Look instead at what the measure is really telling you in terms of the NHAS primary goals • Does the measure tell you anything about access to care? • The quality of the care received? • Retention in care? • Are your client’s eligible for your programs?

23. Quality of Care • Percent of clients who had two or more CD4 T-cell counts in the measurement year, one in the first half and one in the second half. • Percent of clients who had two or more Viral Load counts in the measurement year, one in the first half and one in the second half. • Percentage of active clients with a CD4 count below 200cells/mm3 who were prescribed prophylaxis during the measurement year • Percentage of clients who have a documented SAMISS completion in CAREWare during measurement year.

24. Retention in Care • Percent of clients who had two or more medical visits in an HIV care setting during the measurement year. • Percent of clients who are newly enrolled with a medical provider with prescribing privileges who had a medical visit in each of the 4 month periods in the measurement year.

25. Monitored Viral Load Suppression • Track and monitor viral loads of HIV positives for the following: • State of Idaho broken out by • Race • Ethnicity • Gender • Risk factor • Health Districts(7) • Race • Ethnicity • Gender • Risk factor • Question from committee was how to handle outliers? • Follow-up required- ARV’s prescribed, reduced VL?

26. Program Eligibility Measures • Proportion of clients recertified for eligibility every six months • Percentage of clients accessing services with eligibility documented in CW (HIV status, Income, Insurance Status)

27. RWPB Contracts Provider contracts: 5.Provide HIV Medical Case Management services in accordance with the rules, regulations, policies, and procedures as written in the Idaho Ryan White Part B HIV Medical Case Management Policies and Procedures Manual. This manual can be found on the Family Planning, STD and HIV Programs website www.safesex.idaho.gov under HIV Care and Treatment. 6.Ensure staff providing direct services to clients attend monthly conference calls with the RWPB Program staff and attend all mandatory trainings as deemed necessary by the Program. a. Annual HIV Medical Case Management training in Boise as determined appropriate by the program. Contracts include performance metrics specific to contract management and monitoring.

28. RWPB Policy and Procedure Manual Manual includes: • All RWPB and some RWPC polices and eligibility • Current copy of MCM forms also at www.safesex.idaho.gov • Statewide Quality Management Plan which includes performance measures and QI projects • CAREWare Data Entry Manual with data element definitions, print screens, and step by step instructions.

29. Contractors Quality Management • Each provider has their own policy and procedure manual. • Reviewed and approved to be in compliance with the RWPB Policies and Procedures • Require each contractor to work on Quality Improvement within each agency • Contractors will be required to report on QI projects • Work in progress……

30. CONTRACTS Julia Schlueter, MPH, NQC Fellow Quality Manager Washington University School of Medicine St. Louis, MO

31. FIRST STEP– IDENTIFY WHERE YOU ARE • Grantee – Mission/Vision = Quality Management Plan (Checklist) • Identify Subcontractors – Share Grantee’s Quality Management Plan • Include Quality Management Component within the contracts (see example) • Identify how subcontractors are collecting data. • Work on unifying data collection methodology. • As a Network identify indicators that are relevant to all the subcontractors (1-3) • Identify indicators that are relevant to each subcontractor • Clinical Indicators • Non- clinical indicators should be always link to or aim to assure disease management

32. CONTRACT STEPS CONTINUED 8. Clarify annual quality goals and establish benchmarks - Network - Provider 9. Identify and communicate how and when meetings and reports are going to take place. 10. Identify individuals responsible for reporting at each provider site. 11. Providers should share their quality projects with the network - Annual storyboard success celebration 12. Offer TA to subcontractors to identify goals, objective, improvement projects. 13. Involve consumers in the process.

33. CONTRACT SAMPLE 1 V. MISCELLANEOUS 1. Changes 2. Grant Related Income  • Reporting Example 1: XXXX agrees to provide client-level data on any and all patients served with these funds. These data will be used to satisfy federally-mandated reporting requirements and progress reports and include but are not limited to: patient demographics, HIV/AIDS status, financial eligibility, type and number of services provided, and biological or other health outcome indicators that support the grantee’s (insert grantee name) Clinical Quality Management program. XXXX will provide HIV/AIDS treatment and/or services in accordance with the U.S. Public Health Service and the HRSA HIV/AIDS Bureau guidelines. Data will be entered directly into the grantee’s CAREWare data system (monthly) or shall be provided (at the end of each quarter) via a provider data export (PDE) file that is compatible with the grantee’s CAREWare system.Complete data requirements are specified in Appendix C. 4. Civil Rights and Equal Employment Opportunity

34. CONTRACT SAMPLE 2 • General Principles II. Description of Support a. Mission of grantee and previous performance of clients served. Include projection for next year. b. Key Activities by funded position i. Include QI responsibilities by position. Ex: clinical quality management activities for the Part C/D Network including site-based quality team meetings (at least 8 meetings/year) and updating the Part C/D Quality Manager regularly on XXXX’s quality management activities. III. Responsibilities and Specific Outcomes Expected of XXXX IV. Grantee responsibilities – include monitoring of service delivery and data, clinical monitoring in coordination with Part A, fiscal monitoring

35. CONTRACT SAMPLE 2 • Example of Responsibilities and Specific Outcomes Expected of XXXX • Program representative(s) attend scheduled Part C/D Provider Meetings (quarterly) and other meetings as requested to support coordination of quality services across the Network; • Develop and maintain annual clinical quality management goals that align with the Part C/D Network goals • Implement a Clinical Quality Management program that evaluates how the XXXX clinic works and make changes where necessary, document all agenda, activities and minutes; • Conduct at least 8 quality team meetings each year • Execute at least 4 PDSA cycles for the selected quality indicator each year • At minimum, select a new quality project to work on each year • At minimum, quarterly review indicator data • Track data necessary for HRSA data reporting and contribute this information to the centralized database (e.g., XXX) in a timely manner, including at minimum data necessary to compile the following reports: • Quarterly Part C/D Progress Report (see Attachment B for Part D Work Plan) • Annual Ryan White Services Report (RSR) (http://www.careacttarget.org/topics/rsr.asp) • Monthly Progress Updates with HRSA Part C/D Project Officer

36. Case Study—Working With Sub-Grantees on Quality Management Alberta Lin Ferrari Baltimore-Towson Part A

37. Baltimore-Towson’s Part A Program • Scope: • Baltimore city plus 6 counties, • 9,753 PLWH/A served • Over 20 categories, • 37 sub-grantees and • 140 service contracts. • Some sub-grantees serve thousands of Ryan White clients and have dedicated QI staff, • Others serve hundreds and have staff who multi-task. • Services provided to PLWH/A of all ages/genders—clients are 62% male, median age 47, 84% African-American.

38. Sub-Grantee Contracts • CQM requirements: Sub-grantees must • Have a quality management plan in place • Cooperate with CQM reviewers • Respond to any areas needing improvement • CQM expectations: Sub-grantees also • Participate in Technical Assistance • Identify QI projects • Report back on their progress

39. Perspective • Clear distinction between CQM and Contract Management reviews. • CQM reviews’ objective is improving quality • Contract management review’s objective is ensuring compliance with contracts. • Initial skepticism of QI reviews (and occasional resistance) • With time and care sub-grantees have developed collaborative relationships with a shared mission of improving quality.

40. CQM Reviews 1. Chart reviews of multiple service categories on a rotating 4-year schedule, although primary medical care services are reviewed every year. QI staff: • Perform chart reviews of services provided the prior FY. Chart review tools measure performance against local standards of care, PHS standards, HAB quality indicators, • Provide immediate impressions (de-briefing), • Analyze EMA-wide data, • In the spring, host TA sessions (details to follow), • In summer, provide sub-grantees with reports comparing their performance with that of their peers, identifying strengths and areas for improvement.

41. CQM Reviews (continued) 2. Agency Assessment • Has changed over time. Initially looked at licensures, compliance with Public Health Standards • Past three years have focused on assessments of sub-grantees QI structures, processes and outcomes. • Short self-assessment for two years • This year, Organizational Quality Assessment Tool developed by HIVQUAL-US and The NY Department of Health’s AIDS Institute 3. Consumer satisfaction interviews focused on the categories under review.

42. Technical Assistance Sessions • Series of 2-3 sessions for Core Services • Separate sessions for Supportive Services • QI training provided • Tools from the National Quality Center such as the PDSA cycle, fishbone analysis, writing a quality management plan. • Special topics such as results from special projects, techniques for effective communication with clients, becoming a patient-centered medical home.

43. Technical Assistance Sessions (continued) • EMA-wide results of the review are presented • Participants select EMA-wide areas for improvement—indicators that all sub-grantees will work on improving • Participants brainstorm and select QI projects appropriate for their agency • At the second TA, sub-grantees provide structured reports on their projects and learn from one another

44. Payoff to Sub-Grantees • De-briefings provide immediate feedback on reviewers’ impressions of areas for improvement • TA sessions provide both QI training and opportunity for sub-grantees to share experiences with QI challenges and projects • QI tools are modeled for adoption at sub-grantee agencies • Additional TA is provided to individual sub-grantees at their request, and “QI 101” is provided occasionally for new staff

45. Clinical Outcome Improvements

46. Process Improvements • Reduction in missing data • Improvements in eligibility verification • Increased proportion of clients having other insurance—use of Ryan White as payer of last resort

47. CASE STUDY Claudia Medina, MD, MHA, MPH Assistant Director / Quality Management FACES – Children’s Hospital , LA

48. Participant Exercise • Each group will be given an example of a HIV Agency: mission/purpose, goals, subcontractor agencies and results of measures from each of the agencies • Groups identify a: 1) facilitator, 2) scribe, 3)reporter • Identify, based on all the information: • Appropriate measure(s) to improve the Agency performance • Potential focus of improvement for each of the subcontractors • Challenges to making this work • Solutions to mitigate the challenges

49. HELPING YOUR SUBCONTRACTORS TO FIND THEIR BASE LINE • Subcontractor has someone responsible for data collection? • Subcontractor has a clear process in place to collect data? • Subcontractors understand the Performance Measurement? • Subcontractors have a clear definition of the indicator they are tracking? Denominator/Numerator • Subcontractors understand how to do a fish bowl, flowchart process, PDSA. etc.? • Subcontractors are aware of Grantee goals? • Subcontractors need TA?

50. Non-Clinical Indicators / Clinical Indicators = One Overall Quality Management Plan • Main purpose off all Ryan White Parts is to assure HIV disease management through different services. • How do you know if patients are having their disease manage? • Start small, start SMART • Specific • Measurable • Attainable • Realistic • Timely • Make your non-clinical / clinical. Make them count! There is only ONE target! QUALITY OF CARE