Quality Institute #2
Session 2: Guidance to Creating a
Culture for Quality: How to Work with
your Subcontractors on Quality
Management
Sherry Martin, NQC Coach, Claudia Medina, NQC Fellow,
Julia Schlueter, NQC Fellow
Thursday, November 29, 2012 8 am to 9:30 am
Delaware A
RWA-0248
1
National Quality Center [NQC]
NQC and Quality Workshops at 2012 AGM
2
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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National Quality Center [NQC]
Session Agenda
• Key success factors to achieve high performance results
• Successful strategies used to engage subcontractors- Part A,
B, C and D agencies
• Group exercise – identification of measures on which to
focus improvement initiatives; challenges and potential
solutions
• Key learning points – group reports
4
National Quality Center [NQC]
Learning Objectives
• Describe the importance of aligning subcontractor agency
quality management plans and improvement initiatives with
those of the grantee and/or the National AIDS Strategy
• Identify the critical few opportunities for improvement for
subcontractors based upon results of measures and national
information and goals
• Describe methods used successfully to ensure accurate,
consistent and timely data on key measures and subcontractor
engagement in the quality program
• Implement improvement initiatives across the network to
encourage a unified sustained approach
5
National Quality Center [NQC]
Key Success Factors to Achieve High Performing
Results
• Alignment of goals, measures, improvement initiatives to
achieve mission and national strategy goals
• Accurate and consistent data collection methods and
definitions
• Contractual agreements that define quality program
expectations
• Strong guidance and tools – service plans, education forums,
one-on-one data assistance
6
National Quality Center [NQC]
The Mission/Purpose Statement
The Focus of the Quality Program
• Describes the core function of the network and
delineates the scope of services
• May describe the vision for the future
• Directs and prioritizes network goals and action plans
• Aligns the organization with subunits
• Drives all strategic decisions
7
National Quality Center [NQC]
Mission Statement Examples
• Our mission is to develop and maintain a state-wide quality
program that improves patient health outcomes for
individuals living with HIV. The vision is to become trendsetters in quality health care initiatives.
• The (network name) Network’s mission is to: provide
comprehensive family-centered health care and support
services for women, youth, children and families infected
with or affected by HIV in (State/Region/City).
8
National Quality Center [NQC]
Alignment – Key Success Factor
All stakeholders should understand and agree to the
tenets of the Mission, Vision and/or Purpose
Statements
– Rethink and articulate the mission/vision/purpose
occasionally with all stakeholders
– Align with current national treatment information,
including the National AIDS Strategy
– Communicate in multiple ways, frequently
– Align with reward, recognition and accountability
programs
9
National Quality Center [NQC]
Alignment – Key Success Factor
Quality Infrastructure, Plans and Contracts
• Agency Quality Committee includes leaders from each
subcontractor agency
• Agency Quality Plan (Purpose) is endorsed by all agencies and
reviewed annually
• Subcontractor Quality Plans include relationship with the
agency, common goals and methods
• Contracts with subcontractors describe quality program
expectations
10
National Quality Center [NQC]
Alignment – Key Success Factor
Accurate and Consistent Data
• Measure definitions must be consistently applied at
all sites; this requires validation
• Sampling methods must be consistent
• Source data must be accurate
• Data collection must be frequent enough to provide
usable information
• Results should be arrayed against time (run or
control charts) for analysis
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National Quality Center [NQC]
Alignment – Key Success Factor
Identification of Measures to Improve
• Identify measures to improve performance on the basis
of results and current national and local information,
including the National AIDS Strategy
• Prioritize the selection on the basis of those that will
progress the network to their mission
• Include all subcontractor representatives in the selection
• Define data collection logistics together – data sources,
sampling methods, definitions, frequency of reporting
and formatting
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National Quality Center [NQC]
Alignment – Key Success Factor
Improvement Initiative Direction and Guidance
• All subcontractors identify an agency measure on which
to focus improvement work based upon their results
• Subcontractors use quality methods to identify
opportunities to improve the network measure and to
conduct an improvement project
• Network provides help with data collection and submission
and quality improvement methods
• Progress on measures are reviewed regularly
• Improvement strategies are shared formally and regularly
• “Home runs” are celebrated
13
National Quality Center [NQC]
Measures to Evaluate Mission/Purpose Progress
Our mission is to develop and maintain a networkwide quality program that improves patient health
outcomes for those individuals living with HIV. The
vision is to become trend-setters in quality health care
initiatives and family centered care.
What are possible measures that might be selected to
achieve this vision?
14
National Quality Center [NQC]
Potential Measures for Improvement Focus
• Patient outcome (and surrogate) measures
– Mortality
– Viral Load Suppression – ( National AIDS Strategy)
• Process measures
– Retention- in- Care; Medical Visits – ( National AIDS
Strategy)
– New patients
• Results are in the “trendsetter class”
– Best practice clinics
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National Quality Center [NQC]
Measures to Evaluate Mission/Purpose Progress
The (network name) Network’s mission is to: provide
comprehensive family-centered health care and support
services for women, youth, children and families infected
with or affected by HIV in (State/Region/City).
16
National Quality Center [NQC]
Potential Measures to Evaluate Mission
• Patient HIV outcome measures segregated by
women, youth, children
• Primary care measures – diabetic, asthma, cardiac
• Family engagement measures identified through
various listening posts
 Surveys
 Focus groups
17
National Quality Center [NQC]
Idaho HIV Care Programs
A low incident state’s experience with
quality management programs.
BeBe Thompson
RW Part B/ADAP Coordinator
Idaho Dept. of Health and Welfare
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National Quality Center [NQC]
The Challenge
HIV/AIDS Treatment Cascade.
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National Quality Center [NQC]
A LITTLE BACKGROUND
Idaho HIV Care:
• Low incidence state (1,254 PLWH/A, 12/31/2010)
• Ryan White Part B and Part C’s only
• Staff and funding limited
• All state, clinic and contractor staff have many roles
• RWPB funds HIV monitoring labs and medical case management
• Part C’s provide nearly all clinical and primary care for Idaho’s
HIV positive
Challenge:
• How do we align our quality management activities to the National
HIV/AIDSStrategy?
• Statewide measures encompassing all clinics and contractors
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National Quality Center [NQC]
Part B and Part C Interactions
• Different data collection and measure exclusions
• HIV Qual versus HAB Performance Measures
• Choose one and stick to it for statewide measures
Focus on the strategy’s three primary goals:
1. Reducing the number of people who become infected
with HIV
2. Increasing access to care and improving health
outcomes for people living with HIV
3. Reducing HIV-related health disparities
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National Quality Center [NQC]
NQC Consultant and Idaho QM Committee
• Move away from categorizing in clinical and non-clinical
•
•
•
•
•
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measures
Look instead at what the measure is really telling you in terms
of the NHAS primary goals
Does the measure tell you anything about access to care?
The quality of the care received?
Retention in care?
Are your client’s eligible for your programs?
National Quality Center [NQC]
Quality of Care
• Percent of clients who had two or more CD4 T-cell counts in
the measurement year, one in the first half and one in the second
half.
• Percent of clients who had two or more Viral Load counts in the
measurement year, one in the first half and one in the second
half.
• Percentage of active clients with a CD4 count below
200cells/mm3 who were prescribed prophylaxis during the
measurement year
• Percentage of clients who have a documented SAMISS
completion in CAREWare during measurement year.
23
National Quality Center [NQC]
Retention in Care
• Percent of clients who had two or more medical
visits in an HIV care setting during the
measurement year.
• Percent of clients who are newly enrolled with a
medical provider with prescribing privileges who
had a medical visit in each of the 4 month periods in
the measurement year.
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National Quality Center [NQC]
Monitored Viral Load Suppression
• Track and monitor viral loads of HIV positives for the
following:
State of Idaho broken out by
1.
•
•
•
•
Health Districts(7)
2.
•
•
•
•
•
•
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Race
Ethnicity
Gender
Risk factor
Race
Ethnicity
Gender
Risk factor
Question from committee was how to handle outliers?
Follow-up required- ARV’s prescribed, reduced VL?
National Quality Center [NQC]
Program Eligibility Measures
• Proportion of clients recertified for eligibility every
six months
• Percentage of clients accessing services with
eligibility documented in CW (HIV status, Income,
Insurance Status)
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National Quality Center [NQC]
RWPB Contracts
Provider contracts:
5.Provide HIV Medical Case Management services in accordance with the rules,
regulations, policies, and procedures as written in the Idaho Ryan White Part B HIV
Medical Case Management Policies and Procedures Manual. This manual can be found
on the Family Planning, STD and HIV Programs website www.safesex.idaho.gov
under HIV Care and Treatment.
6.Ensure staff providing direct services to clients attend monthly conference calls with the
RWPB Program staff and attend all mandatory trainings as deemed necessary by the
Program.
a. Annual HIV Medical Case Management training in Boise as
determined appropriate by the program.
Contracts include performance metrics specific to contract management and
monitoring.
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National Quality Center [NQC]
RWPB Policy and Procedure Manual
Manual includes:
• All RWPB and some RWPC polices and eligibility
• Current copy of MCM forms also at www.safesex.idaho.gov
• Statewide Quality Management Plan which includes performance
measures and QI projects
• CAREWare Data Entry Manual with data element definitions,
print screens, and step by step instructions.
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National Quality Center [NQC]
Contractors Quality Management
• Each provider has their own policy and procedure manual.
• Reviewed and approved to be in compliance with the RWPB
Policies and Procedures
• Require each contractor to work on Quality Improvement within
each agency
• Contractors will be required to report on QI projects
• Work in progress……
29
National Quality Center [NQC]
CONTRACTS
Julia Schlueter, MPH, NQC Fellow
Quality Manager
Washington University School of Medicine
St. Louis, MO
30
National Quality Center [NQC]
FIRST STEP– IDENTIFY WHERE YOU ARE
1.
2.
3.
4.
5.
Grantee – Mission/Vision = Quality Management Plan (Checklist)
Identify Subcontractors – Share Grantee’s Quality Management Plan
Include Quality Management Component within the contracts (see
example)
Identify how subcontractors are collecting data.
Work on unifying data collection methodology.
6.
As a Network identify indicators that are relevant to all the subcontractors
(1-3)
7.
Identify indicators that are relevant to each subcontractor

Clinical Indicators

Non- clinical indicators should be always link to or aim to assure
disease management
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National Quality Center [NQC]
CONTRACT STEPS CONTINUED
8. Clarify annual quality goals and establish benchmarks
- Network
- Provider
9. Identify and communicate how and when meetings
and reports are going to take place.
10. Identify individuals responsible for reporting at each
provider site.
11. Providers should share their quality projects with the
network
- Annual storyboard success celebration
12. Offer TA to subcontractors to identify goals, objective,
improvement projects.
13. Involve consumers in the process.
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National Quality Center [NQC]
CONTRACT SAMPLE 1
V.
1.
2.
3.
MISCELLANEOUS
Changes
Grant Related Income
Reporting
Example 1: XXXX agrees to provide client-level data on any and all patients served
with these funds. These data will be used to satisfy federally-mandated reporting
requirements and progress reports and include but are not limited to: patient
demographics, HIV/AIDS status, financial eligibility, type and number of services
provided, and biological or other health outcome indicators that support the grantee’s
(insert grantee name) Clinical Quality Management program. XXXX will provide
HIV/AIDS treatment and/or services in accordance with the U.S. Public Health
Service and the HRSA HIV/AIDS Bureau guidelines. Data will be entered directly into the
grantee’s CAREWare data system (monthly) or shall be provided (at the end of each quarter) via a
provider data export (PDE) file that is compatible with the grantee’s CAREWare system.
Complete data requirements are specified in Appendix C.
4. Civil Rights and Equal Employment Opportunity
33
National Quality Center [NQC]
CONTRACT SAMPLE 2
I. General Principles
II. Description of Support
a. Mission of grantee and previous performance of clients served. Include projection
for next year.
b. Key Activities by funded position
i. Include QI responsibilities by position.
Ex: clinical quality management activities for the Part C/D Network
including site-based quality team meetings (at least 8 meetings/year) and
updating the Part C/D Quality Manager regularly on XXXX’s
quality
management activities.
III.
Responsibilities and Specific Outcomes Expected of XXXX
IV. Grantee responsibilities – include monitoring of service delivery and data, clinical
monitoring in coordination with Part A, fiscal monitoring
34
National Quality Center [NQC]
CONTRACT SAMPLE 2
III. Example of Responsibilities and Specific Outcomes Expected of XXXX
•
•
•
•
Program representative(s) attend scheduled Part C/D Provider Meetings (quarterly) and other meetings
as requested to support coordination of quality services across the Network;
Develop and maintain annual clinical quality management goals that align with the Part C/D Network
goals
Implement a Clinical Quality Management program that evaluates how the XXXX clinic works and
make changes where necessary, document all agenda, activities and minutes;
 Conduct at least 8 quality team meetings each year
 Execute at least 4 PDSA cycles for the selected quality indicator each year
 At minimum, select a new quality project to work on each year
 At minimum, quarterly review indicator data
Track data necessary for HRSA data reporting and contribute this information to the centralized
database (e.g., XXX) in a timely manner, including at minimum data necessary to compile the following
reports:
 Quarterly Part C/D Progress Report (see Attachment B for Part D Work Plan)
 Annual Ryan White Services Report (RSR) (http://www.careacttarget.org/topics/rsr.asp)
 Monthly Progress Updates with HRSA Part C/D Project Officer
35
National Quality Center [NQC]
Case Study—Working With Sub-Grantees on
Quality Management
Alberta Lin Ferrari
Baltimore-Towson Part A
36
National Quality Center [NQC]
Baltimore-Towson’s Part A Program
• Scope:





Baltimore city plus 6 counties,
9,753 PLWH/A served
Over 20 categories,
37 sub-grantees and
140 service contracts.
• Some sub-grantees serve thousands of Ryan White
clients and have dedicated QI staff,
 Others serve hundreds and have staff who multi-task.
• Services provided to PLWH/A of all ages/genders—
clients are 62% male, median age 47, 84% AfricanAmerican.
37
National Quality Center [NQC]
Sub-Grantee Contracts
• CQM requirements: Sub-grantees must
 Have a quality management plan in place
 Cooperate with CQM reviewers
 Respond to any areas needing improvement
• CQM expectations: Sub-grantees also
 Participate in Technical Assistance
 Identify QI projects
 Report back on their progress
38
National Quality Center [NQC]
Perspective
• Clear distinction between CQM and Contract
Management reviews.
 CQM reviews’ objective is improving quality
 Contract management review’s objective is ensuring
compliance with contracts.
• Initial skepticism of QI reviews (and occasional
resistance)
• With time and care sub-grantees have developed
collaborative relationships with a shared mission of
improving quality.
39
National Quality Center [NQC]
CQM Reviews
1. Chart reviews of multiple service categories on a
rotating 4-year schedule, although primary medical care
services are reviewed every year. QI staff:
• Perform chart reviews of services provided the prior FY.
Chart review tools measure performance against local
standards of care, PHS standards, HAB quality indicators,
• Provide immediate impressions (de-briefing),
• Analyze EMA-wide data,
• In the spring, host TA sessions (details to follow),
• In summer, provide sub-grantees with reports comparing
their performance with that of their peers, identifying
strengths and areas for improvement.
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National Quality Center [NQC]
CQM Reviews (continued)
2. Agency Assessment
 Has changed over time. Initially looked at licensures,
compliance with Public Health Standards
 Past three years have focused on assessments of subgrantees QI structures, processes and outcomes.
• Short self-assessment for two years
• This year, Organizational Quality Assessment Tool
developed by HIVQUAL-US and The NY
Department of Health’s AIDS Institute
3. Consumer satisfaction interviews focused on the
categories under review.
41
National Quality Center [NQC]
Technical Assistance Sessions
• Series of 2-3 sessions for Core Services
• Separate sessions for Supportive Services
• QI training provided
 Tools from the National Quality Center such as the
PDSA cycle, fishbone analysis, writing a quality
management plan.
 Special topics such as results from special projects,
techniques for effective communication with clients,
becoming a patient-centered medical home.
42
National Quality Center [NQC]
Technical Assistance Sessions (continued)
• EMA-wide results of the review are presented
• Participants select EMA-wide areas for
improvement—indicators that all sub-grantees will
work on improving
• Participants brainstorm and select QI projects
appropriate for their agency
• At the second TA, sub-grantees provide structured
reports on their projects and learn from one another
43
National Quality Center [NQC]
Payoff to Sub-Grantees
• De-briefings provide immediate feedback on reviewers’
impressions of areas for improvement
• TA sessions provide both QI training and opportunity
for sub-grantees to share experiences with QI challenges
and projects
• QI tools are modeled for adoption at sub-grantee
agencies
• Additional TA is provided to individual sub-grantees at
their request, and “QI 101” is provided occasionally for
new staff
44
National Quality Center [NQC]
Clinical Outcome Improvements
2009
2011
87%
93%
Clients with two or more CD4 tests 78%
88%
AIDS-defined clients prescribed
highly active antiretroviral therapy
(HAART)
89%
95%
Undetectable Viral Load
42%(2007) 51%
Clients with two or more medical
visits during the year
45
National Quality Center [NQC]
Process Improvements
• Reduction in missing data
• Improvements in eligibility verification
• Increased proportion of clients having other
insurance—use of Ryan White as payer of last resort
46
National Quality Center [NQC]
CASE STUDY
Claudia Medina, MD, MHA, MPH
Assistant Director / Quality Management
FACES – Children’s Hospital , LA
47
National Quality Center [NQC]
Participant Exercise
• Each group will be given an example of a HIV Agency:
mission/purpose, goals, subcontractor agencies and
results of measures from each of the agencies
• Groups identify a: 1) facilitator, 2) scribe, 3)reporter
• Identify, based on all the information:
– Appropriate measure(s) to improve the Agency performance
– Potential focus of improvement for each of the subcontractors
– Challenges to making this work
– Solutions to mitigate the challenges
48
National Quality Center [NQC]
HELPING YOUR SUBCONTRACTORS TO
FIND THEIR BASE LINE
1.
2.
3.
4.
Subcontractor has someone responsible for data collection?
Subcontractor has a clear process in place to collect data?
Subcontractors understand the Performance Measurement?
Subcontractors have a clear definition of the indicator they
are tracking? Denominator/Numerator
5. Subcontractors understand how to do a fish bowl, flowchart
process, PDSA. etc.?
6. Subcontractors are aware of Grantee goals?
7. Subcontractors need TA?
49
National Quality Center [NQC]
Non-Clinical Indicators / Clinical Indicators =
One Overall Quality Management Plan
1. Main purpose off all Ryan White Parts is to assure HIV disease management
through different services.
2. How do you know if patients are having their disease manage?
3. Start small, start SMART
a. Specific
b. Measurable
c. Attainable
There is only ONE target!
QUALITY OF CARE
d. Realistic
e. Timely
4. Make your non-clinical / clinical. Make them count!
50
National Quality Center [NQC]
CASE STUDY
• BEFORE YOU START KNOW YOUR GRANTEE
MISION AND VISION
• WHAT IS YOUR GRANTEE GOAL
• MAP YOUR SUBCONTRACTORS
• UNDERSTAND THEIR SERVICES, POLICIES
AND PROCEDURES
• CREATE SERVICE/DATA DICTIONARY
• SUPPORT THEM
51
National Quality Center [NQC]
Measures to Evaluate Mission/Purpose Progress
Our mission is to develop and maintain a network-wide
quality program that improves patient health outcomes for
those individuals living with HIV.
The vision is to become trend-setters in quality health care
initiatives and family centered care.
What are possible measures that might be selected to achieve
this vision?
52
National Quality Center [NQC]
GOALS OF THE QUALITY MANAGEMENT
PROGRAM
•
•
•
•
•
•
•
53
To promote and build quality into the program’s organizational structure and process.
To conduct strategic planning that includes the grantee and its sub-recipients and
stakeholders
To provided effective monitoring and evaluation of client outcome indicators and
service delivery to ensure that services meet accepted performance standards.
To ensure that services provided are positively perceived by clients, the provider
network, and the community.
To ensured prompt identification and analysis of opportunities for improvement with
implementation of actions and follow-up.
To coordinate quality management activities.
To maintain compliance with local, state, and federal regulatory requirements and
accreditation standards, and specifically, to assure that the program is responsive and
consistent with the Ryan White Treatment Modernization Act.
National Quality Center [NQC]
CASE STUDY
Network EXAMPLE with 10 providers divided as
follow:
Service Category fund by Grantee
54
Site
Type of Provider
Funding
Sources for
that Provider
A
CHC
Part A,C,D
Youth & Adult
B
UNIVERSITY.
Part B,C,D
Youth & Adult
C
CBO
Part A, D
D
HOSPITAL
Part D
Pediatric Only
E
CHC
Part A,C,D
Youth & Adult
F
UNIVERSITY
Part A,C,D
Youth and
Adult
G
CBO
H
Medical Case
Management
Non-Medical
Case
Management
Mental
Health
Other
Support
Service
X
X
X
X
Part A, D
X
X
X
X
HOSPITAL
Part B
X
I
UNIVERSITY
Part D,C,A
Youth & Adult
J
UNIVERSITY
Part D
Youth & Adult
Primary Care
National Quality Center [NQC]
Complete Region Data for Performance Measurements
Data as of July 31, 2011
AVERAGE Network TOP
PART D
Goal
25%
IHI
GOAL
A
B
C
D
F
G
H*
I
J
K
CD4
58%
56%
35%
21%
82%
16%
51%
28%
50%
45%
44%
75%
79%
90%
VL
55%
60%
34%
18%
82%
16%
51%
8%
46%
55%
42%
75%
N/A
N/A
MV
72%
76%
34%
35%
47%
41%
74%
40%
64%
86%
57%
80%
N/A
N/A
HAART IN
AIDS
89%
86%
37%
64%
89%
0%
72%
22%
93%
100%
65%
90%
100%
90%
PCP
51%
67%
N/A
0%
0%
9%
N/A
0%
93%
0%
22%
75%
100%
95%
ARV PREG
43%
100%
100%
0%
0%
100%
49%
95%
N/A
N/A
Neonatal
AZT
45%
29%
0%
94%
42%
95%
N/A
N/A
PCR
exposed
35%
24%
0%
69%
32%
95%
N/A
N/A
55
100%
National Quality Center [NQC]
Where to Start?
 Appropriate measure(s) to improve the Network
performance
 Potential focus of improvement for each of the
subcontractors
 Challenges to making this work
 Solutions to mitigate the challenges
56
National Quality Center [NQC]
WHERE ARE WE?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
57
CD4
VL
MV
HAART IN
AIDS
PCP
ARV PREG
Neonatal
AZT
PCR exposed
AVERAGE PART D
44%
42%
57%
65%
22%
49%
42%
32%
NetworkGoal
75%
75%
80%
90%
75%
95%
95%
95%
National Quality Center [NQC]
58
National Quality Center [NQC]
Ryan White Part D Network In Louisiana
How are we doing?
Performance
Measure
CD4
Viral Load
MV
HAART IN AIDS
PCP Prophylaxis
AR
Jul-11
44%
42%
64%
65%
22%
Part D Jul12
62%
61%
72%
78%
50%
120%
GOAL
75%
75%
80%
90%
75%
100%
80%
Jul-11
60%
40%
V Pregnancy
Neonatal AZT
PCR Exposed
49%
42%
32%
96%
79%
57%
95%
95%
95%
Part D Jul-12
GOAL
20%
0%
59
National Quality Center [NQC]
NQC Offerings
NQC Website
HIVQUAL
Regional Groups
in+care Campaign
Quality Academy
On-Site TA
NQC Trainings
60
NQC Resources
61
Sherry Martin
National Quality Center Coach
sherry@martinconsultants.net
National Quality Center
212-417-4730
NationalQualityCenter.org
Info@NationalQualityCenter.org