An Introduction to Performance Measurement for Quality Improvement

1. Introduction to Quality Session 301 Building a Sound Quality Management Infrastructure An Introduction to Performance Measurement for Quality Improvement Lori DeLorenzo, Jennifer Keller & Terry Bray Thursday, November 29,8:00-9:30 am Virginia C RWA-0245

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. Agenda • Welcome and Introductions • QM Committee • QM Plan • Interactive Exercises

5. Who’s in the Audience? Part Role Experience with Quality Management Committees and Quality Management Plans

6. Most Pressing Question? What are you struggling with the most as it relates to Quality Management Committees and QM Plans?

7. Assess your quality management program using organizational assessment tools and learn how to use findings to strategically improve your program Understand how to set up and sustain an effective quality management committee Develop/update your quality management plan with key elements in collaboration with key stakeholders Learning Objectives

8. HAB Expectations for Quality Management A Quality Management Program should consist of a systematic process with identified leadership, accountability and dedicated resources and uses data and measureable outcomes  to determine progress toward relevant, evidence-based benchmarks. • Infrastructure • Performance Measurement • Quality Improvement

10. Components of Quality Infrastructure Leadership Quality Committee Quality Planning

11. Role and Purpose of Quality Committee?

12. Strategic planning Facilitating innovation and change Providing guidance and reassurance Allocating resources Establishing a common culture Responsibilities of the Quality Management Committee

13. Points to Ponder Who leads the Committee? Who should be on the Committee? What is the role of senior leadership as it relates to the Committee? How often should the Committee be meeting?

14. Points to Ponder What areas should the Committee be routinely be reviewing? To whom and about what should the Committee be regularly communicating? Should the Committee be linked to other organizational committees?

15. HIV Quality Improvement Organizational Chart

17. Kansas City TGA QM Advisory Committee Structure

18. Exercise: Assessing Your Quality Committee Fill out the Quality Committee portion (A2) of the organizational assessment (3-4 min) Share with someone you don’t know what is working well and what needs improvement (10 min) Use the action planning form to take notes

19. Select a chair who will be the quality program’s champion Build a cross-functional group: draw from different service areas in the program Include individuals who have influence and can get things done Start small: recruit those most critical to the program’s success Include consumers Tips for Success

20. Include consumers Train committee members on quality improvement Document the activities and progress Celebrate the successes Others? Tips for Success

21. Purpose of QM Plan?

22. Describes how the quality management program is structured, implemented & evaluated Establishes accountability and delineates responsibilities Identifies performance measurement strategies & goals Prioritize improvement goals and projects Purpose of a Quality Management Plan

23. Quality statement Quality infrastructure Performance measurement Quality improvement methodology Participation of stakeholders, including consumers Communication strategy Annual quality goals Evaluation Primary Elements of a Quality Management Plan

24. Describes the purpose of the HIV quality program “ To provide the best possible care to HIV+ individuals in Central Brooklyn.” The end toward which ALL program activities are directed Quality Statement

25. Leadership – ultimate responsibility Membership – cross functional representation Roles & responsibilities Meeting structure Facilitator/leader Reporting mechanisms Frequency Resources Quality Infrastructure

26. Identifies and quantifies the critical aspects of care and services Integration with other Parts or accrediting bodies Identifies measures to determine the progress of the QM Program Performance Measurement

27. Who is accountable for collecting, analyzing, and reviewing performance data and results How to report and disseminate results and findings Communicate information about quality improvement activities Use data to develop new QI activities to address identified gaps Performance Measurement

28. Quality Improvement Methodology Approach to QI teams Link to annual plan

29. Participation of Stakeholders Internal & external stakeholders in the QM program Provides opportunities for learning about quality for staff Includes community representatives, as appropriate How feedback is gathered from key stakeholders

30. Outlines process to share information with all stakeholders Identifies format for communication Identifies communication intervals Communication Strategy

31. Quality goals are endpoints or conditions Few measurable and realistic goals annually (not more than 5); uses a broad range of goals Goals are established priorities for the QM Program Establishes thresholds at the beginning of the year for each goal Annual Quality Goals

32. Specifies timelines for implementation to accomplish those goals – workplan Specifies accountability for implementation steps Provides milestones and associated measurable implementation objectives QM Plan Implementation

35. Evaluates the effectiveness ofthe QM/QI infrastructure Evaluates QI activities to see if annual quality goals are met Reviews performance measures to document whether the measures are appropriate Evaluation

36. Exercise: Assessing Your QM Plan Fill out the Quality Management Plan portion (A3) of the organizational assessment (3-4 min) Share with someone you don’t know what is working well and what needs improvement (10 min) Use the action planning form to take notes

37. Tips for Success Build in a routine process to update the QM plan Use someone outside of the process to review and provide comments Modify plan to meet YOUR agency’s needs Don’t create it as a “bookshelf” plan—use it! Others?

38. NQC Offerings NQC WebsiteQuality Academy HIVQUAL Regional GroupsOn-Site TA in+care CampaignNQC Trainings

39. NQC Resources

40. www.nationalqualitycenter.org Quality Academy tutorials are great to “prescribe” before meetings for all participants to increase their knowledge. Measuring Clinical Performance: A Guide for HIV Health Care Providers. A publication of the AIDS Education Training Centers and the New York State Department of Health, AIDS Institute, 2006. The guide can be downloaded at: http://nationalqualitycenter.org/index.cfm/6127/13908 Additional Resources Resources

41. Lori DeLorenzo, RN, MSNNational Quality Center (NQC) Consultantloridelorenzo@comcast.netJennifer Keller, MPHClinical Quality Administrator at Wake Forest University Medical Centerjekeller@wfubmc.eduTerry BrayQuality Manager for Kansas City Part A Programterry_bray@kcmo.org

42. National Quality Center • 212-417-4730NationalQualityCenter.orgInfo@NationalQualityCenter.org