Funded by HRSAHIV/AIDS Bureau

An Introduction to Performance Measurement for Quality

ImprovementLori DeLorenzo, Jennifer Keller & Terry BrayThursday, November 29, 8:00-9:30 amVirginia CRWA-0245

Introduction to QualitySession 301Building a Sound Quality Management Infrastructure

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NQC and Quality Workshops at 2012 AGM

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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...

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Agenda

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

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Who’s in the Audience?

• Part• Role• Experience with Quality Management

Committees and Quality Management Plans

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Most Pressing Question?

• What are you struggling with the most as it relates to Quality Management Committees and QM Plans?

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Learning Objectives

• 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

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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

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Components of Quality Infrastructure

• Leadership

• Quality Committee

• Quality Planning

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Role and Purpose of Quality Committee?

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Responsibilities of the Quality Management Committee

• Strategic planning• Facilitating innovation and change• Providing guidance and reassurance• Allocating resources• Establishing a common culture

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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?

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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?

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HIV Quality Improvement Organizational Chart

*A designee from this Sub-Committee serves on the QI Committee.

BOARD OF DIRECTORS

QUALITY IMPROVEMENT COMMITTEE

QI ACTIVITIES

Utilization Review/Case Management Complaints/Grievances

Access & Availability Credentialing/Peer Review

Pharmacy Delegated Group (Health Right)

Monitoring Patient Satisfaction/Complaints

HIV QI Sub-Committee* (Team leaders of HIV QI Project Team) President/CEO

Chief Medical Officer

Director, Quality Improvement

Practitioners/Providers

Quality Oversight Committee

HIV QI Site Teams

Upper Cardozo

HC

First Street HC

Phoenix HC

FCS HC At

CCNV

East of the River

HC

MD-1 RN-2 MA-1 PFS- 1 MR- 1

RN- 1 SW- 1 MA- 2

HCM- 1 AMD- 1 RN- 1 MA- 1 PFS- 1

HCM- 1 MD- 1 RN- 1 MA- 1

MD- 2 RN- 2 MA- 1

South-west HC

MD-1 RN-2 SW- 1 MA-3 PFS- 1

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Kansas City TGA QM Advisory Committee Structure

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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

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Tips for Success

• 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

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Tips for Success

• Include consumers• Train committee members on quality

improvement• Document the activities and progress• Celebrate the successes• Others?

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Purpose of QM Plan?

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Purpose of a Quality Management Plan

• 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

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Primary Elements of a Quality Management Plan

• Quality statement• Quality infrastructure• Performance measurement• Quality improvement methodology• Participation of stakeholders, including

consumers• Communication strategy• Annual quality goals• Evaluation

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Quality Statement

• 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

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Quality Infrastructure

• Leadership – ultimate responsibility• Membership – cross functional

representation• Roles & responsibilities• Meeting structure

Facilitator/leader Reporting mechanisms Frequency

• Resources

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Performance Measurement

• 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

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Performance Measurement• 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

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Quality Improvement

• Methodology• Approach to QI teams• Link to annual plan

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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

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Communication Strategy

• Outlines process to share information with all stakeholders

• Identifies format for communication

• Identifies communication intervals

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Annual Quality Goals

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

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QM Plan Implementation

• Specifies timelines for implementation to accomplish those goals – workplan

• Specifies accountability for implementation steps

• Provides milestones and associated measurable implementation objectives

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Evaluation

• Evaluates the effectiveness of the QM/QI infrastructure

• Evaluates QI activities to see if annual quality goals are met

• Reviews performance measures to document whether the measures are appropriate

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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

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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?

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NQC Website

Quality Academy

NQC Offerings

HIVQUAL Regional Groups

On-Site TA

in+care Campaign

NQC Trainings

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NQC Resources

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Additional Resources

• 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

Resources

Lori DeLorenzo, RN, MSNNational Quality Center (NQC) Consultant

loridelorenzo@comcast.net

Jennifer Keller, MPHClinical Quality Administrator at Wake Forest University

Medical Centerjekeller@wfubmc.edu

Terry BrayQuality Manager for Kansas City Part A Program

terry_bray@kcmo.org

National Quality Center

212-417-4730

NationalQualityCenter.org

Info@NationalQualityCenter.org