0

Performance and Quality Improvement Plan

Fiscal Year 09/01/14-08/31/15

Approved by: R. Shannon Hall, Executive Director

Contributing PQI Team Members:

Marianne Wetherill, Erin Vance, Casey Bakhsh, Mark Smalley, Micah Hartwell, Samantha Franklin, Bruce Lewis

1

I. Introduction

A. Organization’s Philosophy of PQI

B. PQI Structure

C. Stakeholders

II. Measures and Outcomes

A. Long-term Strategic Goals and Objectives

B. Management / Operational Performance

C. Program Results / Service Delivery Quality

D. Client and Program Outcomes

III. PQI Operational Procedures

A. Data Collection and Aggregation

B. Data Review and Analysis

C. Communicating Results

D. Using Data for Implementing Improvement

E. Assessment of the Effectiveness of the PQI Process

2

I. Introduction

A. Organization’s Philosophy of PQI (PQI 1) Tulsa CARES is an agency that embraces and promotes a culture of improvement. Agency values include

the integration of quality assurance and quality improvement into daily operations, strategic planning, and

board development.

The PQI Process

The organization uses the PQI process as a vital tool to identify areas that would benefit from quality

improvement initiatives in regards to the goals and objectives stemming from the Strategic Plan.

The Tulsa CARES PQI process provides the framework to create best practices through: a) identification

of organization-wide and program-specific issues, b) implementation of solutions that improve overall

efficiency, and c) delivery of accessible, effective, and high quality services (PQI 2).

B. PQI Structure, Activities, and Roles The PQI structure is community-wide including internal stakeholders, external stakeholders, and a core

PQI team.

1. The PQI Chair

The Chair of the PQI team represents a member of the administrative team dedicated to knowledge (data

and information) management. The organization supports the ongoing professional development of the

PQI Chair to ensure competency in quality improvement, including training and experience in collecting,

analyzing, and communicating results of data in addition to implementation of evaluation methods (PQI

3.01).

2. The PQI Team

The PQI team consists of strategic administrative decision makers, direct service personnel, and program

directors. All PQI team members are expected to engage employees and other stakeholders throughout the

organization in quality improvement initiatives. All team members will be expected to serve as a role

model for PQI involvement and will be evaluated by their supervisor on their participation in program

improvement.

See PQI standard 3.03 for a list of requirements from PQI team members.

Team Chair: Director of Quality Improvement and Risk Management

Member: Director of Support Services

Member: Director of Program Development

Member: Nutrition Program Director

Member: Mental Health Program Director

Member: Direct Care Staff

The team will meet at minimum four times per fiscal year.

Data is reviewed quarterly as follows:

Quarter 1 (September 1– November 30) by January 15

Quarter 2 (December 1– February 28) by April 15

3

Quarter 3 (March 1 – May 31) by July 15

Quarter 4 (June 1 – August 31) by October 15

See appendix A [PQI Organizational Structure]

C. Stakeholders (PQI 2.03)

External Stakeholders include the following:

Foundations

Government agencies (OSDH, City of Tulsa, Oklahoma Housing Finance Agency)

Tulsa Area United Way

Clients

Individual Donors

Community-based organizations such as OKEQ, H.O.P.E., and others

Council on Accreditation

Internal Stakeholders include:

Tulsa CARES Board of Directors

Tulsa CARES Executive Director

Tulsa CARES employees

Tulsa CARES volunteers

Tulsa CARES interns

Input from external stakeholders is facilitated by the PQI team via surveys, invitation to workgroup

meetings, and community newsletters. Internal stakeholders are responsible for directing PQI initiatives,

participating in workgroups, disseminating findings with internal and external stakeholders, and

establishing quality benchmarks and goals (PQI 2.03b).

4

II. Measures and Outcomes PQI information is used to make strategic decisions, build organizational capacity, and monitor the

quality and impact of the organization’s services on the community and on the lives of persons served

(PQI 1) both long term and short term.

A. Long-term Strategic Goals and Objectives Long-term goals and objectives related to quality improvement are referenced in the Strategic Plan (PQI

1) and are supported by the organization’s leadership. During the strategic planning cycle, the Board of

Directors reviews quality measures and assesses the organization’s capacity to effectively meet these

goals (GOV 6.03).

See Appendix B

B. Management / Operational Performance Tulsa CARES will use the PQI process to achieve both long and short term administrative goals,

including 1) strengthen and build the organization’s capacity; 2) measure progress toward achieving

strategic goals; 3) evaluate functions that influence the capacity to deliver services; and 4) mitigate risk

(PQI 4).

See Appendix C

C. Program Results / Service Delivery Quality PQI information is used to make improvements to the accessibility, availability, and efficiency of

HIV/AIDS social services to eligible clients.

See Appendix D

D. Client and Program Outcomes Each program will evaluate client outcomes according to improvements in

clinical status including retention in medical care,

permanency of life situation,

quality of life, and/or

achievement of individual service goals (PQI 4.02).

III. PQI Operational Procedures

A. The Improvement Cycle (PQI 2.02) Tulsa CARES uses the Plan, Do, Study, Act (PDSA) model to outline how PQI information will flow

through the organization, the mechanisms for review, and decision making.

5

B. The PQI Operational Procedure The PQI team is responsible for promoting and participating in the PQI process, including the operational

procedure outlined below.

Identify long term and short term strategic goals;

Identify areas for improvement to help the organization meet those goals,

Develop projected solutions for quality improvement;

Set improvement targets;

Develop outcome measures and indicators;

Complete project tasks and meet project milestones;

Participate in the collection of data;

Meet reporting requirements;

Participate in objective data interpretation;

Apply data to improve practices and outcomes (PQI 3.03).

See Appendix E for Operational Procedure Flowchart

The team is responsible for encouraging broad-based support of established goals.

The team will accomplish the standards outlined in PQI 3.03 by the formation of work groups, which will

invite and encourage participation from both internal and external stakeholders (See Appendix A – PQI

Organizational Structure).

C. Data Collection and Aggregation Tulsa CARES collects and monitors PQI data through various information systems including:

RW CAREWare

QuickBooks

Donor Perfect

Incident Reporting procedure

Excel Spreadsheets

Stakeholder feedback channels, such as client comment box, email, social media, etc.

6

Other sources of data include ongoing case record reviews (audits), quarterly review of risk management

data, annual client satisfaction surveys, and employee training records. Case record reviews are

conducted by employees from other programs. During the audit, a standardized form is used. On a

quarterly basis, closed files are audited at random. Findings from case record reviews are reported back

to the program directors and to the PQI team in order to identify areas of progress and needed

improvement (PQI 4.03).

D. Data Review and Analysis The PQI Team reviews performance measure data and PQI indicators on a quarterly basis and makes

suggestions for improvement. This allows for cross-program communication of quality improvement

efforts.

E. Communicating Results Reports developed and communicated to internal and external stakeholders can include performance

dashboards, reports of gains made against goals, and annual scorecards (PQI 6).

Results will be communicated with other stakeholders through the agency’s annual report and other

documents which will include comparisons of the agency’s performance to national benchmarks or

targets (PQI 7).

F. Using Data for Implementing Improvement PQI performance measure reports and status of improvement projects is reviewed at quarterly PQI

meetings to guide improvement strategies. This allows for cross-program communication of quality

improvement efforts.

The agency will develop an annual PQI report for the governing body and staff that summarizes key PQI

activities, reviews successes, identifies holdover issues from prior PQI annual reports, and helps drive

PQI priorities and goals for the coming year (PQI 7.04).

G. Assessment of the Effectiveness of the PQI Process The organization uses the Plan, Do, Study, Act (PDSA) cycle to evaluate the effectiveness of the PQI

process. The organization also consults with quality improvement experts, including the Manager of Care

Quality and Data Analysis at the Oklahoma State Department of Health.

Tulsa CARES is dedicated to the replication of good practice and to the development of solutions based

on the findings and feedback presented in PQI 6 (PQI 7.01).

7

Appendix A: PQI Organizational Structure

8

Appendix B: Long Term Strategic Goals and Objectives

The long-term strategic goals of the organization are informed by the National HIV/AIDS Strategy1, the

Institute of Medicine Consensus Report on Monitoring HIV Care in the United States2, Healthy People

20203, and emerging needs of the community.

These sources outline strategic goals and objectives in the fight against HIV/AIDS as improving the lives

of those living with HIV/AIDS by:

Diagnosing those infected;

Linking them to care;

Retaining them in care;

Giving them access to anti-retroviral therapy;

Achieving a low viral load and improved CD4 count

Appendix C: Management/Operational Performance Tulsa CARES will use the PQI process to achieve both long and short term administrative goals,

including:

Raise the organization’s profile in the community;

Improve employee engagement;

Increase physical and program operations capacity;

Obtain new sources of funding;

Increase organizational compliance with best practices and legal regulations; and

Mitigate risk.

Appendix D: Program Results/Service Delivery Quality Tulsa CARES will use the PQI process to achieve strategic goals, including:

Increasing the accessibility of services to meet the needs of HIV/AIDS community in

Northeastern Oklahoma

Increasing the availability of a wide range of services to help meet the mission of the organization

and to address service gaps and barriers;

o Service gaps and barriers (according to the OSDH 2012 Comprehensive Plan)

Legal Services

Employment Services

Medical Transportation

Dental Care

1 Office of National AIDS Policy (2010). National HIV/AIDS strategy for the United States. Accessed on July 12, 2012 at http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf. 2 National Research Council (2012). Monitoring HIV care in the United States: Indicators and data systems. Washington, DC: The National Academies

Press.

33 U.S. Department of Health and Human Services (2010). Healthy People 2020. Accessed on July 12, 2012 at

http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf

9

Insurance Assistance

Nutritional Counseling

Emergency Financial Assistance

Inpatient Services

Evaluating the efficiency of service delivery.

Appendix E: Operational Procedures Flowchart

10

COMPONENT OTHER PARTICIPATING COMPONENTS

PDSA Cycle

Outputs

PQI Philosophy Organization’s Values Organization’s Vision Organization’s Mission

Plan Vision Statement Mission Statement

PQI Plan / PQI Process PQI Team Plan PQI Plan

PQI Operational Procedures PQI Team Plan PQI Procedures

Long Term Strategic Plan (every 3 to 5 years)

Board of Directors Program Leadership

Plan Strategic Plan

Annual Plan Identification of key improvement initiatives (operational, process, projects)

Based on current assessment: Quality Improvement baselines

Plan Annual Plan Measurement baselines

PQI Quality Improvement Goals worksheet

PQI Team Plan Do

PQI Goals and Objectives Project Mgmt Documentation, Tasks, Action Items

Project Management Milestones, tasks, and action items

PQI workgroups (Program Directors) and PQI Chair

Implement and execute improvement plans, Make observations Record data

PQI workgroups (Program Directors) and PQI Chair Monthly Program Directors Meetings

Do Monthly Mgmt Packet Updates to Project Mgmt doc as execution occurs

PQI Quarterly Performance Measure Review (monitor and track)

PQI Team Study

PQI Quarterly Meeting Minutes PQI Annual Report

PQI Quarterly Meetings and Project Management Documentation make suggestions and changes to improve; update improvement plans; update project management documentation; update reports

PQI Team Act Revision of Project Management documentation

qu

arte

rly

ann

ual

ly

qu

arte

rly

ann

ual

ly