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									                      NQC National TA Call:
           Developing QM Infrastructure:
             Examples and Solutions
                  from the Field
               March 13, 2008, 3 – 4 pm EST
           Nanette Brey Magnani, EdD, NQC Quality Consultant

     Hollie Malamud-Price, MPH, Part D Program Coordinator, Michigan
                     Department of Community Health

    Rosemary Donnelly, MSN, APRN, HIV Nurse Consultant, HIV Section,
                    Georgia Division of Public Health

1                           1                          National Quality Center (NQC)

    • Purpose and components of a written Quality
      Management Plan

    • Purpose and tips for Quality Management

    • Challenges and solutions related to QM Plans
      and QM Committees

2                                     National Quality Center (NQC)
    Infrastructure enhances systematic implementation of
                    improvement activities


3                                          National Quality Center (NQC)
              Quality Management Plan

       Provides direction of what needs to be
        accomplished (goals) and how it will be
        accomplished (workplan)
       Clear indication of who is responsible
       Sets the framework for holding grantee and
        providers accountable for its accomplishments
       Basis for self-evaluation for next cycle of

4                                          National Quality Center (NQC)
       Grantee-wide Vision

    Strategic QM Plan (3-5 yrs)

        QM Plan (annual)

          Annual Goals



        Annual Evaluation

5                                 National Quality Center (NQC)
          Key Components of an Annual QM Plan

    1.   Quality Statement
    2.   Infrastructure
    3.   Performance Measurement – 5/8/08 TA Call
    4.   Annual Quality Goals – integrated into 7/10/08 TA Call
    5.   Stakeholder Development – integrated into series
    6.   Consumer Involvement – 9/10/08 TA Call
    7.   Evaluation
    8.   Workplan

6                                                National Quality Center (NQC)
               Part 1: Quality Statement

    What do we want to be?

    • Describe the end goal of the HIV quality program to
      which all other activities are directed

    • Assume an ideal world and ask yourselves, "What do
      we want to be for our patients and our community?―

7                                           National Quality Center (NQC)
          Quality Statement Example

    The Positive Health Care program provides
    comprehensive HIV primary care and
    prevention services to persons in Southern
    Maine. Positive Health Care is committed to
    the delivery of high quality care to our
    patients. We strive to continuously improve
    the quality of care consistent with recognized
    national standards, current research, and
    Ryan White Care Act guidelines.

8                                     National Quality Center (NQC)
     Part 2: Quality Improvement Infrastructure

    How are we organized?
        Who is responsible for the grantee-wide quality
       improvement initiatives?

       Who is responsible for making changes?
       How does it get reported?
       How are consumers involved? Other major

9                                             National Quality Center (NQC)
     Part 2: Quality Improvement Infrastructure

     Quality Committee Structure
        Membership
        Leadership
        Charge, plan, reporting

        Budget
        Staffing
        Time and assistance from MIS
        Volunteers

10                                      National Quality Center (NQC)
     Part 2: Quality Improvement Infrastructure

     • List internal and external linkages

     • Draw an organization diagram/chart to depict how
       HIV Quality Program relates to other committees,
       groups, departments in organization, sub contracting
       agencies, other RW programs.

11                                           National Quality Center (NQC)
         Example: Georgia – QM Committees

     QM Core Team
     Sub committees
        Performance Measures
        Case Management
     Coordination with Other Statewide QI/QA Activities
        across Ryan White Programs
        within DPH
        with ADAP
        Communication with Key Stakeholders

12                                         National Quality Center (NQC)
                                                       MDCH – Ryan White Part D Quality Management System

                                                                                                                            Part D                                    Ryan White Cross Part
                                                                                                                    MDCH Program Coordinator                            Quality Committee

                                                                                                                   Part D Executive Committee
                                                                                                                    Quality Mgmt Committee
                                                                                                                 Members & Representatives from
                                                                                                                        Funded Agencies

                                                                                                                         (Meets Quarterly)

                                                                                                                Part D Sub-Contractor Quality Mgmt

                                                                                   DMC                                                     APM                             VNA                       Wellness                      DHWP                       CARES

                                                                                                                                                   Care Services Monthly          Monthly Quality                                     Quarterly Quality Mgt
Horizons                                        UHC                                                  PIDC                       CHM                   Team Meetings              Committee Meeting
                                                                                                                                                                                                            Weekly Case Mgt Mtgs
                                                                                                                                                                                                                                        Team Meetings

                                                                                                                                                                                                                                               Monthly Mgmt Team Mtgs
                                                                                                                                                                                                                                               Bi-Monthly Case Mgr Mtgs
               Quarterly Evaluation Mtg                                                                                     Project Challenge
                                                           Quarterly QM Committee Mtg                QI Group
             Bi-Monthly Mgmt Team Mtgs                                                                                  Monthly Team Meetings,
                                                                                                                               Includes QI
                                                                                                                           Immunology Clinic
                                                                                                                       Bi-Monthly Mgmt Team Mtgs

 **All subcontracted agencies minimally participate in contractual Quality Improvement activities.

  13                                                                                                                                                                                        National Quality Center (NQC)
          Part 3: Performance Measurement

     How will we assess progress?

     • Identify and quantify the critical aspects of care and
       services provided in your HIV program

     • Develop indicators and measure progress

14                                              National Quality Center (NQC)
               Example: Michigan Part D

     Quality indicators are chosen for review from
       the following areas:
     • Clinical/medical primary care
     • Coordination of services
     • Case management
     • Outreach/peer support/advocacy
     • Continuity of care
     • Psycho social and mental health services

15                                      National Quality Center (NQC)
             Part 4: Annual Quality Goals

     What are the priorities for the quality

     • Quality goals are endpoints or conditions toward
       which a quality program directs its efforts and

16                                      National Quality Center (NQC)
                     Example: Michigan Part D Program

Function/Performance            Goals for 2008                              Program
Measure                                                                     Responsible

Documentation of a pap          75% of eligible female patients will have   UHC, PIDC,
smear (statewide indicator)     documented test results and/or copies       Horizon’s Project
                                from an outside provider.
                                # of women with annual Pap smears/#
                                of women with 1 medical visit in the 12
                                month period.

Documentation of case           90% of clients will have a care plan        Horizons, APM,
management care (service)       documented and updated at least every       CARES, VNA,
plans (statewide indicator)     six months.                                 Wellness

Clients with identified needs   Increase from 51% to 75% the number         UHC
will have documentation of      of Part D eligible client charts which
referrals.                      documented coordination of services
                                among 2 disciplines.

17                                                                  National Quality Center (NQC)
                Example: Georgia, Part B

     • Percent of HIV-infected clients with AIDS who were
       prescribed HAART. (Goal 90%)

     • Percent of HIV-infected clients on HAART with HIV
       viral loads < 75 copies/mL. (Goal 50%)

     • Percent of ADAP applicants approved or denied for
       ADAP enrollment within two weeks of the ADAP
       receiving a complete application. (Goal 95%)

18                                            National Quality Center (NQC)
     Georgia example cont’d.

     • Percent of ADAP enrollees recertified for ADAP
       eligibility criteria at least annually. (Goal 95%)

     • RW funded providers will implement cont. quality
       improvement mechanisms within their own agency
       including written QM Plans and a report of most
       recent CQI activities and results.

19                                              National Quality Center (NQC)
         Part 5: Stakeholder Development

     • Assess education needs of

     • Provide training opportunities for staff,
       providers and other stakeholders

20                                    National Quality Center (NQC)
             Example: Michigan Part D Strategy
      Combining Provider Training with Quarterly Meetings

     Combine provider training with quarterly
        participants are staff responsible for quality
         improvement projects
        Agenda includes
          • Program updates
          • Discussion of performance measurements and goals
          • Training topics: QI projects, PDSAs, measuring PDSAs,
            QI tools (not all in one session)
          • Peer exchange of what works

21                                               National Quality Center (NQC)
                  Part 6: Consumer Involvement

     How will consumers be involved in the QM
     • Engage consumers through various mechanisms with
       the intent of increasing their participation over time.

     Moderate Participation     Higher Participation
     Surveys                    Consumer Advisory Boards
     Focus groups               Representation on Quality Committees
     Individual interviews      Representation at Planning Meetings

22                                                  National Quality Center (NQC)
                    Part 7: Evaluation

     How will we evaluate our overall
      performance as a program?
     Evaluation efforts should include:

     • Review of performance data
     • Review of QI Projects conducted over the year
     • Effectiveness of QM Plan

23                                          National Quality Center (NQC)
         Example: Georgia, Part B - Evaluation

            • QM Program Assessment Tool (NQC)
            • Checklist for Review of QM Plan (NQC) to review Plan
            • Rating of Completeness of strategies
     Site Visits
            • Conducted annually
            • Review of subgrantee QM plans and QI activities and
              progress on case management standards and performance
            • Findings reported annually
            • Revised QM Plan for approval

24                                                   National Quality Center (NQC)
               Part 8: Annual Workplan

     How will we implement the QM Plan?
     • The workplan should include:
        List of key activities

        Identification of who is responsible for completing
         or overseeing the completion of activities

        When the activities are to be carried out and
         completed during the year

25                                            National Quality Center (NQC)
                    Example: Georgia, Part B – Annual QM Timeline

                                   Ryan White                                         Mid-Year                       Program                           Obtain
Implement                          Program Part                                       Progress                       Part B                            Internal
Revised QM                         B Final                                            Report                         Grant Due                         Approval
Plan and                           Progress                                           Due                                        Revise QM             for Plan
Workplan                           Report Due                                                                                    Plan &

  April      May       June       July       August      September         October         November         December        January     February      March

             QM Core Team Mtg.                        QM Core Team Mtg.                          QM Core Team Mtg.                    QM Core Team Mtg.
             Review Progress & Update                 Review Progress & Update                   Review Progress &                    Review Progress
             Workplan                                 Workplan                                   Update Workplan                      Review/Approve Revised
                                                      Draft Interim Progress Report              Plan for Next FY                     QM Plan and Workplan
             Finalize Previous FY QM
             Progress Report

 26                                                                                                                    National Quality Center (NQC)
     Issues Identified by Grantees

     Quality Management Plans

27                           National Quality Center (NQC)
     BIG Questions: Who writes the QM Plan?
                    Who needs to be involved?

     • No QM Plan
     • Difficulties with QM Plan Implementation
         Setting goals
         Developing standards of care, quality indicators and
           Not setting priorities
           Inexperience of members (―it can be frustrating‖)
           Not a realistic plan
           No buy-in
           Time consuming
           Conflicting personalities and who is in charge

28                                                     National Quality Center (NQC)
                     Possible Solutions

     Inexperience – ask for training (NQC Quality Academy,
       NQC TA Request, join HIVQUAL Project for Parts C
       & D…); ask a peer grantee for assistance

     Conflicting personalities – bring in someone not
       involved, training can help (NQC)

     Time consuming – don’t reinvent the wheel, check
       NQC website for examples of other QM Plans

     Not a realistic plan; no buy-in – Use a participatory
       planning process

29                                            National Quality Center (NQC)
     Tips for Who is Involved, How and When?

     Decide on your approach to developing/updating
     your QM Plan

      An annual planning meeting

      A series of shorter meetings that could include
       piggybacking/using existing QM committee meetings

      Getting input (for stakeholders who can’t attend
       meetings due to time, distance, etc.)

30                                             National Quality Center (NQC)
     Tips for Who is Involved, How and When?

     Systematize timing for QM Plan updates

        Annually

        Bi-annual updates

31                                    National Quality Center (NQC)
         Quality Management Committees

      Strategic planning
      Facilitating innovation and change
      Providing guidance
      Establishing a QI culture
      Allocating resources

32                                      National Quality Center (NQC)
            Tips for Effective QM Committees

     • Start with a small group of critical individuals
     • Cross- functional representation
     • Include consumers
     • If applicable, include cross-Part reps
     • Clarify purpose/responsibilities of Committee
     • Train members on QI methodologies
     • Identify a Chairperson to moderate
     • Develop a meeting schedule
     • Set agenda and take minutes to document key
     • Communicate Committee activities/decisions with staff,
       providers, and other stakeholders

33                                             National Quality Center (NQC)
        Issues Identified by Grantees

     Quality Management Committees

34                              National Quality Center (NQC)
           Issues regarding QM Committees

     •   Too many sub committees, fractured work
     •   Disinterested in QM
     •   Lack of QM knowledge
     •   Infrequent and inconsistent attendance
     •   Staff turnover
     •   Ineffective relationship between Committee
         Chair and Quality Manager

35                                       National Quality Center (NQC)
           Issues regarding QM Committees

     • Membership turnover – how to get new people
       up to speed. This places a greater burden on
       fewer members to get the work done
     • Membership is voluntary and secondary to
       members’ fulltime jobs
     • Competing demands between Parts A, B, and
       setting up an All Parts QM Committee
     • Not understanding what the QM Committee
       needs to do and how to do it

36                                      National Quality Center (NQC)
       Making Your QM Committee a Success:
            Ideas from Fellow Grantees
     • Oakland meets quarterly instead of monthly to keep up

     • San Juan changed the meeting times to coincide with
       Planning Council meetings

     • To keep members interested and develop their
       knowledge and skills, San Juan and Oakland incorporate
       training and guest speakers at meetings; others trained
       members in how to develop indicators and measures

     • Phoenix schedules meetings in advance so members
       have meetings on their schedules; they want to increase
       their meetings to quarterly; reviewing the QM plan
       annually helps members see what was accomplished
37                                            National Quality Center (NQC)
        Making Your QM Committee a Success:
             Ideas from Fellow Grantees

     • Dallas requires their medical providers to have an active
       role on its Performance Improvement Committee and
       other service providers depending on the issue being

     • Ohio found that once staff were trained in QM they were
       interested in participating in the committee
     • Norfolk saw interest in QM rise following an assessment
       activity when providers said they were enthused about
       doing QI Projects

38                                               National Quality Center (NQC)
        Resource: NQC Quality Management Plan

     Checklist for the
     review of an HIV
     specific Quality
     Management Plan


39                                              National Quality Center (NQC)
     Resource: NQC QM Program Assessment
              Tools (Part- Specific)

       Assessment Tools to
       assess the key
       elements of your QM

40                                        National Quality Center (NQC)
            NQC QM Infrastructure Resources

NQC Quality Academy:
• Tutorial 5: Quality Management Plan
• Tutorial 6: Quality Management Infrastructure

Previous NQC TA Calls:
• April 12, 2007: Developing QM Infrastructure for Part C&D
• March 8, 2007: Developing QM Infrastructure for Part A&B
• June 5, 2006: QM Plans for Part C&D (with sample QM Plans)
• December 15. 2005: QM Plans for Part A&B (with sample QM

2006 RWCA AGM Workshop:
• Strengthen Your Quality Infrastructure by Developing a Sound QM
  Plan (Sample QM Plans: Missouri Part B, Oakland EMA)

41                                                National Quality Center (NQC)
     Today’s Grantee Presenters:

Hollie Malamud-Price, M.P.H.,RWTMA Part D Program
Michigan Department of Community Health, 3056 W. Grand Blvd., Suite 3-150
Detroit, MI 48202; (p) 313.456.4362; (f) 313.456.4427

Rosemary Donnelly, MSN, APRN-BC, ACRN, PHSO Nurse
HIV Section, Georgia Division of Public Health, 2 Peachtree Street, NW, Ste 12-264
Atlanta, GA 30303; (p) 404.463.0415; (f) 404.657.3119;

42                                                         National Quality Center (NQC)
      National Quality Center (NQC)
         NYSDOH AIDS Institute
       90 Church Street—13th Floor
        New York, NY 10007-2919

43          43                National Quality Center (NQC)

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