Building a Sound Quality Management Infrastructure

Introduction to Quality

Session 301

An Introduction to Performance

Lori DeLorenzo, Jennifer Keller &

Terry Bray

Thursday, November 29, 8:00-9:30 am

Virginia C

RWA-0245

Funded by HRSA

HIV/AIDS Bureau

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

National Quality Center (NQC)

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

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


HAB Expectations for Quality Management

8

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


9 National Quality Center (NQC)

10

Components of Quality Infrastructure

• Leadership

• Quality Committee

• Quality Planning


11

Role and Purpose of

Quality Committee?


12

Responsibilities of the Quality Management

Committee

• Strategic planning

• Facilitating innovation and change

• Providing guidance and reassurance

• Allocating resources

• Establishing a common culture


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

B

OARD OF

D

IRECTORS

Q UALITY I MPROVEMENT C OMMITTEE

Quality Oversight Committee

QI ACTIVITIES

Utilization Review/Case Management

Complaints/Grievances

Access & Availability

Credentialing/Peer Review

Pharmacy

Delegated Group (Health Right)

Monitoring

Patient Satisfaction/Complaints

Southwest HC

Upper

Cardozo

HC

First

Street

HC

HIV QI Sub-Committee*

(Team leaders of HIV QI Project Team)

*A designee from this

Sub-Committee serves on the QI Committee.

HIV QI Site Teams

Phoenix

HC

FCS HC

At

CCNV

East of the River

HC

President/CEO

Chief Medical Officer

Director, Quality Improvement

Practitioners/Providers

MD-1

RN-2

SW- 1

MA-3

PFS- 1

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



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

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


20

Tips for Success

• Include consumers

• Train committee members on quality improvement

• Document the activities and progress

• Celebrate the successes

• Others?


21

Purpose of QM Plan?


22

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


Primary Elements 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


24

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


25

Quality Infrastructure

• Leadership – ultimate responsibility

• Membership – cross functional representation

• Roles & responsibilities

• Meeting structure







Facilitator/leader

Reporting mechanisms

Frequency

• Resources


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


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


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

Communication Strategy

• Outlines process to share information with all stakeholders

• Identifies format for communication

• Identifies communication intervals


31

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


32

QM Plan Implementation

• Specifies timelines for implementation to accomplish those goals – workplan

• Specifies accountability for implementation steps

• Provides milestones and associated measurable implementation objectives




35

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


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?


NQC Website

NQC Offerings

HIVQUAL

Regional Groups in+care Campaign

Quality Academy On-Site TA NQC Trainings

38

39

NQC Resources

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

40 Resources National Quality Center (NQC)

Lori DeLorenzo, RN, MSN

National Quality Center (NQC) Consultant loridelorenzo@comcast.net

Jennifer Keller, MPH

Clinical Quality Administrator at Wake Forest University Medical Center jekeller@wfubmc.edu

Terry Bray

Quality Manager for Kansas City Part A Program terry_bray@kcmo.org

National Quality Center

212-417-4730

NationalQualityCenter.org

Info@NationalQualityCenter.org

Building a Sound Quality Management Infrastructure

Role and Purpose of

Quality Committee?

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