Quality Management Program

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Quality Management Program
How can you make this topic entertaining and
keep everyone from falling asleep?

• Clemens Steinböck, MBA

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What are my options?

• Use pictures

3
What are my options?

• Use humor

4
What are my options?

• Use my kids

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What are my options?

• or
• Use the audience
• Via the Audience Response System

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Practice Round Confidence in Health Care

• In which of the following areas do you worry
  about a serious error leading to injury or harm?
  
• Commercial airlines 32
• Food from supermarket 30
• Doctors office 40
• Medicine from pharmacy 34

7
Do you worry about a serious error leading to
injury or harm in a hospital?

• 15
• 27
• 35
• 47
• 65

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1. What does QMP stand for?

• Quantum Mechanics
• Quartz Measurement
• Quality Management
• Quality Measurement

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2. How would you define a Quality Management Plan?

• A work plan outlining annual QI activities (who,
  when, how)
• A written document that outlines the Quality
  Management Program
• Same as Quality Management Program
• Represents the organizational structure of the
  formal HIV Quality Program

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3. Which of the following is the same as a
Quality Management Plan?

• Strategic Plan
• Workplan
• Quality Improvement Project Plan
• None of the above

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4. Which of the following two descriptions
details a QM Plan?

• It encompasses all grantee-specific quality
  activities, including the formal organizational
  quality infrastructure (e.g., committee
  structures with stakeholders, providers and
  consumer) and quality improvement related
  activities (performance measurement, QI project
  and QI training activities).
• It a written document that outlines the
  grantee-wide quality management 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.

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5. Based on HIVQUAL Organizational Assessment
data, which question ranked the LOWEST among
Title III and Title IV providers?

• Does the program have an organizational structure
  to assess/improve the quality of care?
• Does the HIV quality program have a comprehensive
  quality plan?
• Did the HIV leadership support the HIV quality
  program?
• Is the staff routinely educated about quality?

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6. Based on HIVQUAL Organizational Assessment
data, which question ranked the HIGHEST among
Title III and Title IV providers?

• Does the program have an organizational structure
  to assess/improve the quality of care?
• Does the HIV quality program have a comprehensive
  quality plan?
• Did the HIV leadership support the HIV quality
  program?
• Is the staff routinely educated about quality?

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7. Which of the following domains scores the
LOWEST among Title II grantees?

• Statewide Quality Management Plan
• Performance Data are collected statewide
• Quality management committee with appropriate
  membership
• Involvement of DOH agencies (Epi, ADAP, Medicaid

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8. Which of the following domains scores the
HIGHEST among Title II grantees?

• Statewide Quality Management Plan
• Performance Data are collected statewide
• Quality management committee with appropriate
  membership
• Involvement of DOH agencies (Epi, ADAP, Medicaid

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9. Which statement about the QM Plan is true?

• A QI plan should not reference JCAHO and its
  framework for quality improvement
• A QM plan should only address Ryan White funding
  requirements for quality
• A good QI Plan includes the following elements
  Quality statement, Quality improvement
  infrastructure, Performance measurement, Annual
  quality goals, Participation of stakeholders,
  Evaluation.
• A complete QI Plan needs to have at least 15
  pages or more

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10. Which of the following rules to write a QM
Plan is NOT correct?

• If you have not touched your plan in the last 6
  months, bring it to the next quality committee
  meeting
• 80 planning, 20 writing
• Do not reinvent the wheel, use an established
  framework to get started
• The ultimate measure of a good plan is that the
  entire planning group agrees
• A perfect QM plan is probably written by the
  external consultant (and nobody knows anything
  about it)

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11. You are asked to develop annual goals for the
QM Program to be included in the annual plan.
What is NOT your first step?

• Define quality goals are endpoints or conditions
  toward which quality program will direct its
  efforts and resources
• You pick only a few measurable and realistic
  goals annually
• In order to speed up the planning process, you
  might with your colleague, finalize the measures
  and start measuring
• You establish thresholds at the beginning of the
  year for each goal
• You include a wide range of stakeholders in the
  development of the goals, including consumers

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Agenda

• Definitions of Terms
• NYSDOH AIDS Institute Expectations
• Elements of a QM Plan
• How to write/update a QM Plan
• 10 Rules
• Implementation of QM Plan

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Definitions of Terms

• Quality Management Plan A Quality Management
  Plan is a written document that outlines the
  programwide 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.

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Definitions of Terms

• Quality Management Program The term quality
  management program encompasses all
  grantee-specific quality activities, including
  the formal organizational quality infrastructure
  (e.g., committee structures with stakeholders,
  providers and consumer) and quality improvement
  related activities (performance measurement, QI
  project and QI training activities).

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Definitions of Terms

• Strategic Plan A Strategic Plan is document to
  describe the long-term (3-5 years) objectives of
  the QM program with stretch goals that are in
  line with the overall vision of the organization.

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Definitions of Terms

• Workplan A Workplan or Implementation Plan
  describes concrete steps in the implementation of
  an annual QM plan with detailed description of
  responsibilities and timetables and milestones.
  At times the workplan is folded into the overall
  QM Plan.

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Grantee-wide Vision
Strategic QM Plan (3-5 yrs)
QM Plan (annual)
Annual Goals
Workplan
Execution
Annual Evaluation
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NYS Quality Program Standards

• Goals
• to clearly describe the standards for an HIV
  quality program in NYS
• to unify various existing quality program
  expectations into one set of program standards
• to establish standards for all HIV programs in
  NYS regardless of service model or facility size
• to integrate new standards into quality
  expectations for facilities

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NYS Quality Program Standards

• A) Infrastructure for HIV Quality Program
• B) Staff Involvement in Quality Improvement
  Activities
• C) Performance Measurement
• D) Quality Improvement Projects
• E) Consumers Involvement

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A) Infrastructure for HIV Quality Program

• The infrastructure of the quality program should
  be fully described in the quality plan, with a
  clear indication of responsibilities and
  accountability, and elaboration of processes for
  ongoing evaluation and assessment.

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B) Staff Involvement in Quality Improvement
Activities

• 'Staff should be actively involved in the HIV
  Quality Program and its quality improvement
  activities. The participation in the quality
  program should be part of job expectations.
  Provisions should be made for ongoing education
  of staff about quality improvement.'

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C) Performance Measurement

• 'Performance measurement should include clearly
  defined indicators that address clinical, case
  management and other services as prioritized by
  the program. A plan for follow-up of results
  should be outlined.'

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D) Quality Improvement Projects

• 'Quality Improvement activities should be
  conducted based on performance data results.
  Specific quality improvement projects should be
  undertaken which include action steps and a
  mechanism for integrating change into routine
  activities. Quality improvement teams should
  include cross-functional representation.'

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E) Consumers Involvement

• 'Consumers should be included in quality-related
  activities.'

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Organizational Assessment

• Tool to assess the HIV-specific quality structure
  and activities
• benchmarking opportunity
• Share program strengths and identify
  opportunities for improvement

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Elements of a Quality Management Plan
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Elements of a Quality Management Plan

• Quality statement
• Quality improvement infrastructure
• Performance measurement
• Annual quality goals
• Participation of stakeholders
• Evaluation

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Part 1 Quality Statement

• What do we want to be?
• brief purpose/mission statement describing 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?

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Part 1 Quality Statement

• Tips
• Be brief
• Be visionary
• Include internal and external expectations
• Make references to external legislative
  requirements on quality management

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Part 1 Quality Statement ExampleHow do you rate
this mission statement?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Part 2 Quality Improvement Infrastructure

• How are we organized?
• Leadership
• Who is responsible for the program-wide quality
  management initiatives?
• Accountability
• Who are the major stakeholders? What are their
  expectations for the quality management program?
• Quality committee(s) structure
• Who serves on the internal and external quality
  committee(s)? Who chairs the HIV quality
  committee(s)? When will the quality committee
  meet to assess progress and plan future
  activities? How will QM activities be
  communicated?
• Resources
• What are the resources for the QM Program?
  Staffing?

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Part 2 Quality Improvement Infrastructure

• Tips
• Not more than 3-5 pages (not every detail is
  needed)
• Avoid naming individuals (just job functions)
• List internal and external stakeholders
• List linkages

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Part 2 Quality Improvement Infrastructure
Example How do you rate the accountability in
the sample?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Part 3 Performance Measurement

• How will we assess progress?
• identify and quantify the critical aspects of
  care and services provided
• develop indicators and measure the progress of
  the QM Program

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Part 3 Performance Measurement

• Tips
• develop quality indicators, keeping in mind three
  main criteria Relevance, Measurability and
  Improvability
• include the process for reviewing and updating
  the indicators (who/when/how)
• include a portfolio of process, outcome and
  satisfaction measures
• include strategies how to report and disseminate
  results and findings

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Part 3 Performance Measurement Example How do
you rate the completeness of indicators?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Part 4 Annual Quality Goals

• What are the priorities for the quality program?
• Quality goals are endpoints or conditions toward
  which quality program will direct its efforts and
  resources
• Develop a annual goals, the following three
  criteria can be helpful
• Frequency How many patients/clients received and
  how many did not receive the standard of
  care/services?
• Impact What is the effect on patient health if
  they do not receive this care/services?
• Feasibility Can something be done about this
  problem with the resources available?

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Part 4 Annual Quality Goals

• Tips
• pick only a few measurable and realistic goals
  annually (not more than 5)
• use a broad range of goals
• establish thresholds at the beginning of the year
  for each goal

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Part 4 Annual Quality Goals Example How do you
rate the outlined goal?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Part 5 Participation of Stakeholders

• How will staff, providers, consumer and other
  stakeholders be involved in the QM Program?
• Engage internal and external stakeholders
• Communicate information about quality improvement
  activities
• Provide opportunities for learning about quality

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Part 5 Participation of Stakeholders

• Tips
• List internal and external stakeholders and their
  functions/responsibilities
• Include
• Clinical providers
• Non-clinical providers
• Consumers
• Subgrantees
• Representatives from agency, such as hospital,
  network, etc.
• List proposed training opportunities for staff
  and providers

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Part 5 Participation of Stakeholder Example How
do you rate the completeness of this list?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Part 6 Evaluation

• How will we evaluate our overall performance as a
  program?
• Evaluate infrastructure effectiveness
• Was the quality committee effective in its
  efforts to improve the quality of HIV
  care/services? Does the quality infrastructure
  require any changes to improve how quality
  improvement work gets done?
• Evaluate QI activities
• Were annual quality goals for quality improvement
  activities met? How effectively did you meet your
  goals?
• Did the implementation of the annual work plan go
  as planned? Did you meet established milestones?
• Were stakeholders informed about ongoing quality
  activities? Were staff and providers trained on
  QI methodologies and tools?
• Performance measures
• Were the measures appropriate to assess the
  clinical and non-clinical HIV care? Are the
  results in the expected range of performance?

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Part 6 Evaluation

• Tip
• Detail when and who is performing the evaluation
• Compare annual QI goals with year-end results
• Use findings to plan next years activities
  learn and respond from past performance
• Routinely use organizational assessment tools

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Part 6 Evaluation Example How do you rate the
completeness of the evaluation strategies?

• Poor
• Poor-Average
• Average
• Average-Excellent
• Excellent

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Process to Write/Update a QM Plan
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Process to Write/Update a QM Plan

• Step 1 Identify key stakeholders
• Step 2 Decide on a planning approach
• Step 3 Develop and approve QM plan
• Step 4 Strategize to implement the QM plan

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Step 1 Identify key stakeholders

• HIV program staff
• Consumer/family member representatives
• Clinical and non-clinical providers
• etc.

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Step 2 Deciding on a planning approach

• Four strategies to propose a QM plan
• Assignment of key person
• identify individual(s) to propose a QM plan
• Formation of subcommittee
• facilitate one meeting with key stakeholders to
  gather input and draft recommendations
• Series of planning meetings
• break the planning meeting down into smaller
  steps and plan a series of shorter meetings with
  different membership
• Piggyback on QM committee structure
• extent current QI committee meetings to discuss
  QM plan

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Step 3 Develop and approve QM plan

• Tips to develop and approve a program-wide QM
  plan
• Fully understand the environment in which the
  quality improvement program works
• Get input and buy-in in key areas for the quality
  program (consumers, providers)
• Develop a vision for the quality program and
  strategically outline the goals and objectives
• Be inclusive to create ownership and buy-in

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Step 4 Strategize to implement the QM plan

• Develop an annual work plan to answer the what,
  when, where, and how. Include in your work plan
  following elements
• Major quality goals
• concise annual QM objectives
• Quality activities
• internal and external QI activities
• Accountability
• staff person or team(s) are identified to oversee
  and report back on QI activities
• Date of completion
• duration and/or date of activities

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Step 4 Strategize to implement the QM plan
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The 10 QM Plan Rules

• Rule 1 - Size does not matter.
• Rules 2 Additional Pages do not add content to
  a QM plan.
• Rule 3 If you have not touched your plan in the
  last 6 months, bring it to the next quality
  committee meeting.
• Rule 4 80 planning, 20 writing (old software
  programming rule).
• Rule 5 Be inclusive, even it takes longer to
  get your final QM plan.
• Rule 6 Do not reinvent the wheel, use an
  established framework to get started.

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The 10 QM Plan Rules

• Rule 7 A few visionary annual goals are better
  than plenty of useful ones.
• Rule 8 A perfect QM plan is probably written by
  the external consultant (and nobody knows
  anything about it).
• Rule 9 Perfect plans are only as good as its
  implementation.
• Rule 10 If you did not update the plan
  throughout the year, you probably did not look at
  it.

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One more timeDid you fall asleep?

• Yes
• No