funded by hrsa hiv/aids bureau an introduction to performance measurement for quality improvement...

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...

National Quality Center (NQC)4

Agenda

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


Who’s in the Audience?

• Part• Role• Experience with Quality Management

Committees and Quality Management Plans


Most Pressing Question?

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


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

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


Components of Quality Infrastructure

• Leadership

• Quality Committee

• Quality Planning


Role and Purpose of Quality Committee?


Responsibilities of the Quality Management Committee

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


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?


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?


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

Kansas City TGA QM Advisory Committee Structure


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


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


Tips for Success

• Include consumers• Train committee members on quality

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


Purpose of QM Plan?


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

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

consumers• Communication strategy• Annual quality goals• Evaluation


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


Quality Infrastructure

• Leadership – ultimate responsibility• Membership – cross functional

representation• Roles & responsibilities• Meeting structure

Facilitator/leader Reporting mechanisms Frequency

• Resources


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


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


Quality Improvement

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


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


Communication Strategy

• Outlines process to share information with all stakeholders

• Identifies format for communication

• Identifies communication intervals


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


QM Plan Implementation

• Specifies timelines for implementation to accomplish those goals – workplan

• Specifies accountability for implementation steps

• Provides milestones and associated measurable implementation objectives


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


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


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


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

[email protected]

Jennifer Keller, MPHClinical Quality Administrator at Wake Forest University

Medical [email protected]

Terry BrayQuality Manager for Kansas City Part A Program

[email protected]

National Quality Center

212-417-4730

NationalQualityCenter.org

[email protected]

funded by hrsa hiv/aids bureau an introduction to performance measurement for quality improvement...

Documents

quality session

quality workshops

purpose of quality committee

quality management program

quality management committees

quality management plans

national quality center

quality committee portion