Funded by HRSA HIV/AIDS Bureau What is Quality Improvement? What are the Quality Expectations from...

Funded by HRSAHIV/AIDS Bureau

What is Quality Improvement? What are the Quality Expectations from HAB?

Aug 26, 2008

Clemens Steinbock, MBA

Director, National Quality Center

Quality Institute Session 1Quality Institute Session 1

National Quality Center (NQC)2

Agenda

- Opening Remarks

- Overview and Introduction

- Quiz – Group Activity

- Principles of Quality Improvement

- Scenario – Group Activity

- HAB Expectations on Quality

- QI Resources

- Evaluations and Wrap-up


“How can you make this topic entertaining and keep everyone from falling asleep?”


What are my options?

• Use humor



• Use my kids



or

• Use the audience… via the Audience Response System


Quiz


1) What does CQI stand for?

a) Community Quality Initiative

b) Case Management Quality Ideas

c) Continuous Quality Improvement

d) Circular Quantum Invention


2) Why does Quality Improvement become increasingly important in health care?

a) Quality Improvement has been proven to be successful

b) Increasing requirements by regulatory agencies

c) Increasing accountability by programs for the quality of services

d) All of the above


3) What is the main difference between Quality Assurance and Quality Improvement?

a) Quality Assurance uses mainly a team approach

b) Quality Improvement focuses on statistical outliers for improvements

c) Quality Assurance and Quality Improvement is practically the same

d) None of the above


4) What is the most important principle for Quality Improvement? Quality Improvement focuses on…

a) Individual performers

b) Routine measurement of performance

c) Training of providers

d) System’s issues


5) Which of the following statement by HAB is INCORRECT?

a) QM programs need to look beyond clinical services to consider both supportive services and outcomes

b) QM programs assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines

c) The primary focus of the QM program is on performance measurement to assess clinical and non-clinical services

d) Quality is the degree to which a health or social support service meets or exceeds established professional standards and user expectations


6) HAB describes the following characteristics of Quality Management Programs. Which ones are CORRECT?

a) Be a systematic process with identified leadership, accountability and dedicated resources

b) Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks

c) Focus on linkages, efficiencies and client expectations in addressing outcome improvement

d) Ensure that data are fed back into the quality improvement process to assure that goals are accomplished

e) All of the abovef) None of the above


7) The following performance data report is presented: PPD 95%, GYN 85%, and PCP Prophylaxis 55%. You advise the program to continue to measure…

a) only PCP Prophylaxis

b) GYN and PCP Prophylaxis

c) All three indicators


8) The results of an adherence QI project are presented after 10 months of work, improving the rate to 98% and it was kept between 95%-100% for the last 4 months. You advise the program to…

a) Discontinue routine measurements

b) Switch to quarterly measurements

c) Keep monthly measurements


9) Due to the high rate of Mental Health screening (95%), the QI team stopped meeting but continued to measure the rate monthly. Recently the score declined. When should the MH QI team to re-start?

a) 90%

b) 80%

c) 70%


Couple more questions…


What is your professional background?

0%

0%

0%

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0% 1. Clinical Provider (MD, NP, PA)

2. Nurse

3. Case Manager/Social Worker

4. Administrator

5. Other

10


How do you rate your own quality improvement knowledge?

0%

0%

0%

0%

0% 1. Novice

2. Beginner

3. Intermediate

4. Proficient

5. Expert

10


How do you rate your HIV Quality Management Program?

0%

0%

0%

0%

0% 1. Not existing

2. Beginning

3. Sufficient

4. Good

5. Excellent

10


Quality Improvement Quality Improvement PrinciplesPrinciples

Clemens Steinbock, MBA212.417.4730Clemens@NationalQualityCenter.orgNationalQualityCenter.org


Success is achieved through meeting the needs of those we serve.


Most problems are found in processes, not in people.


Do not reinvent the wheel – Learn from best practices.


Learn through small, incremental changes to achieve continual improvements.


Actions are based upon accurate and measured data.


Infrastructure enhances systematic implementation of improvement activities.


Set Priorities and Communicate clearly


Infrastructure

Balance between Data Collection and Quality Improvement Activities


‘QI is not QA’

Quality Assurance Quality Improvement

Motivation Measuring compliance with standards

Continuously improving processes to meet standards

Means Inspection Prevention

Focus Individuals, “bad apples” Processes and Systems

Responsibility Few All


Three Faces of Quality Improvement

Aspect Improvement Accountability(Accreditation)

ClinicalResearch

Aim Improvement of care Comparison, choice, reassurance, spur for change

New knowledge

Test observability Test observable No test, evaluate current performance

Test blinded

Sample size “Just enough” data, small sequential samples

Obtain 100% of available, relevant, data

“Just in case” data

Testing strategy Sequential tests No tests One large test

Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.


HAB’s Working Definition of Quality

“Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol. 1. (1990)


In 1601, James Lancaster successfully conducted an experiment to illustrate the

effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment?

1. 1602

2. 1689

3. 1757

4. 1796


Treatment of Scurvy

• Stephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004

In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster.

In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages.

In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in 1747.

From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy.

In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy.

In 1865 British Board of Trade adopted the policy for the merchant marine.


How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall

in his 1984 Lancet Article?

1. 2 years

2. 5 years

3. 10 years

4. 20 years


Treatment of Ulcer – Marshall

Timetable:

1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients

1981: Dr. Barry Marshall starts residency

1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer

1984: first publication in Lancet; presents treatment of ulcer with common antibioticum

1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. Marshall


In a recent article in the Journal of Quality Improvement 92 QI projects were compared.

What was the timeframe from problem identification to completion of first pilot?

1. 23 days

2. 60 days

3. 397 days

4. 504 days


Survey of 92 Quality Improvement Projects in Journal of Quality Improvement

• Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects.” Journal of Quality Improvement 2001, 27(11): 619-632

• 504 days from problem identification to completion of first pilot

397 days from first team meeting to the end of first cycle

75 days to describe current situation in flowchart

62 days for data collection if change was improvement


How can we accelerate change and improvements in HIV programs?

Model for Improvement


What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do


Model for

Improvement



How will we know that a change is an

improvement?

What change can we make that will result in

improvement?





improvement?


improvement?



ActWhat changes

are to be made?

Next cycle?

PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle (who, what, where, when)

Study Complete the

analysis of the dataCompare data to

predictionsSummarize

what was learned

DoCarry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

The PDSA cycle for learning and improvement


PDSA Cycle to incorporate the use of a new CM form

Introduce new CM Intake/

Assessment Form

Improve Access to

HIV Primary Care

A PS D

APS

D

A PS D

D SP A

DATAD SP A

Cycle 1A: Adapt new CM form and test with one of Joanne’s patients

Cycle 1B: Revise tool and test with Karl’s clients next Monday

Cycle 1C: Present refined tool to all 3 case managers and document feedback

Cycle 1D: Revise and test tool with all clients for one week

Cycle 1E: Implement and monitor the standards


Tips for PDSA Cycles

• “What change could you implement by next Tuesday?”

• Use the “Rule of 1”: 1 facility 1 office 1 provider 1 patient


Tips for PDSA Cycles

• Volunteers at first

• Useful, not perfect, data

• Use “huddles” to report

• Learn from others (‘Steal shamelessly, Share senselessly’)


References

• Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62

• Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81

• Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996

• Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55


HRSA’s 9-Step Model to Quality

Goal of Manual:• provide the tools to develop and

implement a quality management program

• outline a step-by-step process that can be applied in any care setting

• applicable for both the experienced and non-experienced grantee

Developed by HIV/AIDS Bureau Quality Institute



1. Commit Leadership & Supportive Organizational Structure

Establish support of program leadership for Quality Management Delineate specific QM responsibilities of staff

2. Establish Quality Management Plan Establish Quality Committee to oversee the QM program Develop an organizational QM plan which delineates goals and

objectives for the QM program

3. Determine Performance Measures & Collect Data Based on QM priorities, develop/adopt indicators to measure

performance Determine method of data collection and collect data



4. Analyze Data Analyze data and review the results Identify areas where additional data is required

5. Develop Project-Specific CQI Plan Establish project-specific QM team to improve specific aspects of

care/services Develop timeline for reporting findings and improvement

6. Study and Understand the Process Utilize QI tools and techniques to understand the process Report progress to senior leadership and staff



7. Develop and Implement an Improvement Plan Identify potential solutions to make improvement to the

systems of care. Try a small test of change and analyze results.

8. Re-measurement Re-measure indicator after change has been

implemented. Determine need for and/or level of re-measurement on an

ongoing basis.

9. Celebrate Success Communicate results of the project to all levels of the

organization Congratulate team in public forum


References

• HAB Quality Management Manual, HRSA HIV/AIDS Bureau website; hab.hrsa.gov/tools/QM


Scenario – Group Scenario – Group ExerciseExercise

Clemens Steinbock, MBA212. 417 [email protected]


HAB Quality HAB Quality ExpectationsExpectations

Clemens Steinbock, MBA212. 417 [email protected]


Update: Ryan White HIV/AIDS Treatment Modernization Act of 2006 – PL 109-415

• Reauthorized for 2006 - 2009 which sunsets 9/30/09• Increased focus on living HIV and AIDS cases over the last

calendar year • Increased focus on expenditures for core medical services• Increased focus on coordination and integration of care and

prevention at federal, state and local levels• Significant changes include: Part A eligibility definition, funding

formulas, hold harmless percentages, annual sample audits, biannual reports to congress on funds expended, consequences for failure to comply

See a Side-by-side comparison at www.kff.org/hivaids/upload/7531-03.pdf


Ryan White HIV/AIDS Treatment Modernization Act of 2006

• “The chief elected official/ grantee… shall provide for the establishment of a clinical quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services”



• “RWCA grantees are directed to establish clinical quality management programs to …”

• “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…”

• “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV health services”



“RWCA grantees are directed to establish clinical quality management programs..” which include: Development of a comprehensive clinical quality management

infrastructure, including routine QM meetings with cross-functional representation

Description of QM program in a written quality plan, with a clear indication of responsibilities and responsible parties

Inclusion and involvement of key stakeholders in your quality program

Designated leaders for quality improvement and accountability



• “assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines…” which includes: Development and/or adaptation of quality indicators for

key clinical and service categories Routine performance measurement of key care aspects Sharing of performance data with program staff Use of data to improve the organization’s performance

on key services



• “develop strategies for ensuring that such services are consistent with the guidelines for improvement in access to and quality of HIV service…” that include:

Linking performance data results to quality improvement activities

Establishment of quality improvement teams with cross-functional representation

Integration of changes into routine program activities


Key Characteristics of a Quality Management Program

Patient-centeredness is a fundamental focus of quality care and

undergirds the 5 characteristics that follow.

1. A systematic process with identified leadership,

accountability, and dedicated resources available to the

program

2. Use data and measurable outcomes to determine

progress toward relevant, evidenced-based benchmarks

3. Focus on linkages, efficiencies and provider, and client

expectation in addressing outcome improvement


4. A continuous process that is adaptive to change and that

fits within the framework of other programmatic quality

assurance and quality improvement activities

5. Ensure that data collected are fed back into the quality

improvement process to assure that goals are

accomplished and that they are concurrent with improved

outcomes

Key Characteristics of a Quality Management Program (cont.)


Quality Improvement Resources: Quality Improvement Resources: Websites, Publications, Technical AssistanceWebsites, Publications, Technical Assistance


Quality Improvement Websites

NationalQualityCenter.org

• HIV measures• Change ideas• Best practices• Tools/resources• Literature• FAQ


Quality Improvement Websites

www.HIVQUAL.org

• HIV QI publications• Measures• HIVQUAL Project• Clinical guidelines• Recent news and

events


Websites for Quality Improvement

hab.hrsa.gov

• HRSA QI expectations• QI Tools• TA Resources


QI Learning Resources

Starting to Learn about Quality Improvement

Measuring Quality of HIV Care Measurement

Setting up a QM Infrastructure

Writing a Quality Management Plan

Conducting Quality Improvement Activities


QI Teaching Resources

Teaching Quality Improvement Fundamentals

Teaching Performance Measurement

Teaching QM Infrastructure

Teaching Quality Improvement Activities

Teaching Patients on Quality


Consumer Involvement Training Materials

Soliciting Patient Feedback

Empowering Patients to Partner with their Health Care Providers

Maintaining a Patient Health Record

Best Practices for Consumer Involvement

Teaching Providers about Patient Self-Management


Quality Academy (Online Training Course)

• Online quality improvement training course – at no cost available 24/7 (also available on CD-Rom)

• Interactivity through test questions and online exercises

• 20 QI topics from beginner (e.g., QI 101, PDSA) to advanced levels (e.g., dealing with resistance)

NationalQualityCenter.org/QualityAcademy


Quality Improvement Publications


HIVQUAL Software and QM Plan Checklist


HIVQUAL Indicators – Adult and Adolescent

• ARV THERAPY MANAGEMENT

• HIV MONITORING (CD4 and VL testing)

• HIV SPECIALIST CARE

• ANTIRETROVIRAL THERAPY MEDICATION

• TREATMENT EDUCATION

• ADHERENCE TO ARV THERAPY

• PCP PROPHYLAXIS

• MAC PROPHYLAXIS

• GYNECOLOGY EXAMS

• TUBERCULOSIS SCREENING (PPD)

• SYPHILIS SCREENING

• HEPATITIS C SCREENING

• VACCINATION

• SUBSTANCE USE

• MENTAL HEALTH CARE

• DENTAL CARE

• OPHTHALMOLOGICAL CARE

• LIPID SCREENING

• BASIC PATIENT EDUCATION


HIVQUAL Indicators – Pediatric

• ARV THERAPY MANAGEMENT

• HIV MONITORING (CD4 and VL

testing)

• HIV PEDIATRIC SPECIALIST

CARE

• ANTIRETROVIRAL THERAPY

MEDICATION ADHERENCE

• PCP PROPHYLAXIS

• MAC PROPHYLAXIS

• ROUTINE VACCINATIONS

• NEURODEVELOPMENTAL

ASSESSMENTS

• MULTIDISCIPLINARY CARE

PLAN


HIVQUAL Indicators – Case Management

• Case Management Complete psychosocial assessment

Patient Knowledge Screening

Treatment Adherence Assessment

Service Care Plan & Coordination of Care

Access and Continuity

Self-Management: Client Participation in Care Planning


Technical Assistance Resources

National Quality Center (NQC)

NYSDOH AIDS Institute90 Church Street—13th FloorNew York, NY [email protected]


Technical Assistance Resources

National HIVQUAL Project

NYSDOH AIDS Institute90 Church Street—13th FloorNew York, NY 10007-2919212 417 [email protected]


Evaluation


How do you rate this workshop?

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2. Good

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4. So, So

5. Not Very Good

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The workshop kept me interested and engaged?

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2. Agree

3. Neutral

4. Disagree

5. Strongly Disagree

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The workshop gave me practical strategies and solutions to use at my HIV program.

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2. Agree

3. Neutral

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The workshop topic was relevant to me and my HIV program.

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The presenters at this workshop were experts and answered questions effectively.

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The workshop had the right balance of lecture and interactive activities.

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I liked the little remotes….

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10


Thank You :-)


National Quality Center (NQC)

212.417.4730212.417.4730

NationalQualityCenter.orgNationalQualityCenter.org

[email protected]@NationalQualityCenter.org

Funded by HRSA HIV/AIDS Bureau What is Quality Improvement? What are the Quality Expectations from...

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