new york state department of health the hiv quality of care program new york state department of health aids institute

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1 the HIV quality of care program ew york state departmet of health aids istitute the hiv quality of care program ew york state departmet of health aids istitute

2 February 0 Dear Healthcare Provider: We are pleased to provide you with this booklet describig the New York State HIV Quality of Care Program, which was lauched by the New York State Departmet of Health AIDS Istitute i 99. This program is resposible for systematically moitorig the quality of medical care ad support services provided to people livig with HIV i New York State ad for guidig care to achieve iteded health outcomes. Built upo the priciples of cotiuous quality improvemet, the program icludes measuremet of key performace idicators that have bee defied by experts from the provider commuity. Priorities for these measures are joitly agreed upo by providers ad cosumers, together with state ad local health officials. While we maitai attetio to providig balaced healthcare, as our focus turs to edig the HIV epidemic, we are icreasigly focused o three key idicators: likage, retetio, ad viral load suppressio. As part of the treatmet cascade, these focal poits are crucial to both prevetig trasmissio of HIV ad esurig positive health outcomes. This booklet provides a overview of the New York State HIV Quality of Care Program, which is ivolved with the measuremet of quality idicators, the implemetatio of improvemet methods, the presetatio of facility-specific ad statewide data, ad the provisio of quality improvemet coachig services to support ad develop HIV quality programs. Our learig etworks ad regioal groups foster improvemet through peer learig ad targeted o-site coachig. Additioally, our web-based ehivqual performace measuremet system allows providers to geerate immediate facility-level reports to drive their improvemet activities. This New York State program has bee a model for atioal improvemet iitiatives, specifically for the HIVQUAL-US program, which has ow bee itegrated ito the Natioal Quality Ceter, supported by the Health Resources ad Services Admiistratio HIV/AIDS Bureau (HRSA/HAB), ad for global iitiatives through HEALTHQUAL Iteratioal. the hiv quality of care program ew york state departmet of health aids istitute The AIDS Istitute is committed to buildig capacity ad capability for quality improvemet ad has begu to expad its work to iclude improvemet of hepatitis C ad STI care i New York s healthcare facilities. Although we have accomplished much, we still have work to do as we cotiue our missio i partership with providers ad commuities to improve care, targetig our efforts to stem the HIV epidemic ad ed AIDS. Sicerely, Bruce D. Agis MD, MPH Medical Director, AIDS Istitute New York State Departmet of Health

3 aids istitute missio ad visio The AIDS Istitute protects ad promotes the health of New York State s diverse populatio through disease surveillace ad the provisio of quality prevetio, healthcare, ad support services for those impacted by HIV, AIDS, sexually trasmitted ifectios, viral hepatitis, ad related health cocers. We are committed to elimiatig ew ifectios ad improvig the health ad well-beig of impacted commuities. The AIDS Istitute is committed to the followig guidig priciples ad core values: RESPECT: We treat all idividuals impacted by HIV, AIDS, sexually trasmitted diseases, ad viral hepatitis with digity, respect, ad compassio. PARTNERSHIP: We value commuity iput ad collaboratio with federal, state, local, ad commuity parters. LEADERSHIP: We embrace, empower, ad drive chage i the fight agaist HIV, sexually trasmitted ifectios, ad viral hepatitis. STEWARDSHIP: We strive to be creative ad resourceful i plaig, developig, ad deliverig high-quality services to impacted commuities. the HIV quality of care program The New York State Departmet of Health AIDS Istitute is committed to promotig the quality of HIV cliical care ad supportive services for people livig with HIV/AIDS i New York State. The Quality of Care Program edeavors to: Accelerate measurable ad cotiuous progress toward effective ad cosumer-cetered HIV services, stadards of care, ad service delivery i aligmet with the missio of the AIDS Istitute, the Natioal HIV/AIDS Strategy, ad New York State Departmet of Health stadards ad guidelies for the care of people livig with HIV/AIDS Facilitate improvemet of HIV cliical care ad supportive services to achieve positive health outcomes for people livig with HIV/AIDS i New York State To achieve these critical eds, the Quality of Care Program champios a quality maagemet model that icorporates three core elemets: cotiuous performace measuremet; robust quality improvemet activities; ad quality maagemet programs, which are defied as the structure, fuctios, ad processes that support improvemet activities. Through coachig, techical assistace, ad the establishmet of cliical idicators, the Quality of Care Program assists New York State HIV care providers i developig sustaiable, idepedet quality maagemet programs. Curret areas of focus for the Quality of Care Program iclude improvig rates of viral load suppressio, patiet retetio, ad comprehesive metal health screeigs, prioritizig health equity, ad ehacig the use of cliical iformatio systems to geerate data to improve care. Refiemet of measuremet strategies to ehace cliical outcomes is also a major priority for the Quality of Care Program, as is esurig the capacity of all New York State HIV programs to self-report their aual HIV performace data. To this ed, the Quality of Care Program has developed a web-based performace measuremet platform, ehivqual, that eables HIV cliics to directly report their performace measuremet data ad to immediately view reports that facilitate idetificatio of specific areas for cliical care improvemet. the hiv quality of care program ew york state departmet of health aids istitute

4 quality maagemet The capacity to cotiuously improve HIV treatmet, care, ad supportive services depeds o a quality maagemet ifrastructure with the followig features: Active support ad guidace by cliical leadership ad seior admiistratio A writte quality maagemet pla Staff, physicia, ad cosumer ivolvemet i the quality maagemet program stadards for quality of care programs To guide providers i their establishmet of soud quality maagemet programs, the AIDS Istitute has issued Quality of Care Program Stadards that outlie the expectatios for HIV-specific quality programs. These stadards were first drafted i 99 ad were most recetly revised i 0. They are itegrated ito all AIDS Istitute activities ad are applicable to all HIV programs i New York State. STANDARD : Ifrastructure of HIV Quality Maagemet Program HIV quality maagemet programs are actively supported ad formally guided by cliical leadership ad seior admiistratio, which provides istitutioal commitmet ad allocates appropriate resources to esure sustaiable implemetatio of improvemet activities. Program staff are aware of the quality maagemet ifrastructure ad uderstad their roles i improvemet activities. A HIV quality maagemet committee is fully accoutable for HIV-specific improvemet activities, developmet of aual quality improvemet goals, prioritizatio of key quality idicators for review, sharig of HIV performace data with staff ad stakeholders, ad routie evaluatio of the quality maagemet program. The committee membership icludes staff from all key medical ad omedical services. Cosumer represetatives are icluded to provide iput to esure that services effectively meet or exceed patiet eeds ad expectatios. The committee meets at least oce every other moth. HIV quality maagemet programs are effectively liked with the istitutio-wide quality maagemet program. Each HIV quality maagemet program has a writte aual quality maagemet pla that is reviewed ad updated routiely by the quality maagemet committee. A descriptio of quality maagemet ifrastructure ad leadership resposible for program-wide quality maagemet iitiatives, icludig: the iteral ad exteral quality maagemet committee(s) structure; committee chairperso; membership; meetig schedule to assess progress ad pla future activities; ad a pla for commuicatig the quality maagemet program activities. The major stakeholders ad their expectatios for the quality maagemet program should also be idetified, i additio to the resources ad staffig allocated for quality maagemet program activities. Performace measuremet activities describig idicators ad data collectio methodologies Aual improvemet goals based o program priorities Processes for traiig ad egagemet of staff, cosumers, ad stakeholders Procedure(s) for routie evaluatio of the quality maagemet program. The pla is shared with staff ad cosumers to gather iput ad to promote ivolvemet i the quality maagemet program ad its activities. A formal workpla that idetifies implemetatio resposibilities ad a timetable for their completio. The workpla is revised routiely as part of periodic review ad formal evaluatio. STANDARD : Performace Measuremet Performace idicators should guide the developmet ad implemetatio of improvemet activities. The quality maagemet pla describes these performace idicators, icludig their defiitios, sources of data, desired health outcomes, ad frequecy of data collectio. Idicator defiitios are updated at least aually to reflect curret stadards of care. HIV program staff aalyze the performace of core medical ad omedical services at least aually ad coduct more frequet measuremets based o idetified eeds for improvemet. Idicators are chose based o iteral HIV program priorities ad exteral expectatios. At a miimum, idicators measure key health outcomes, such as viral load suppressio. Performace data results are reviewed durig quality maagemet committee meetigs ad are used to guide improvemet activities. A actio pla to address performace gaps icludes a descriptio of implemetatio steps, specific resposibilities, ad a time frame for completio of activities. Performace data results are shared with staff, patiets, ad key stakeholders. the hiv quality of care program ew york state departmet of health aids istitute The pla icludes the followig elemets: A quality statemet describig the overall missio of the quality maagemet program Each HIV program has a fuctioal iformatio system for trackig patiets ad moitorig patiet care. The iformatio system produces meaigful performace data reports that iclude patiet-specific ad aggregate data o key quality of care idicators, such as viral load suppressio ad retetio i care. The system is accessible to staff for routie data review ad for geeratig customized data reports that ca the be used to assess the quality of HIV care.

5 STANDARD : Quality Improvemet Activities Each HIV program selects at least oe ew improvemet project aually. Improvemet activities are idetified ad prioritized by the quality maagemet committee ad are based o performace data results, exteral expectatios, ad cosumer ad staff iput. The quality maagemet committee oversees the progress of iteral quality iitiatives ad ay ecessary actios i respose to exteral audit fidigs. Improvemet teams with cross-fuctioal represetatio, icludig cosumers, are formed to address specific improvemet opportuities ad to moitor chages. Results of improvemet projects are preseted to the HIV quality maagemet committee, shared amog staff ad cosumers, ad used for future plaig. STANDARD : Staff Ivolvemet The quality maagemet committee ad improvemet teams comprise staff members represetig all disciplies, icludig medical providers. Job expectatios ad descriptios require staff ivolvemet i quality maagemet activities. Staff participate i capacity-buildig activities, such as learig etworks or regioal groups, which promote peer learig ad accelerate improvemet project implemetatio. The objectives, progress, ad results of improvemet activities are routiely commuicated to staff to icrease awareess ad participatio i the HIV quality maagemet program. At a miimum, aual improvemet traiig or updates are provided to staff to further build their capacity for quality improvemet. STANDARD : Cosumer Ivolvemet Cosumers are icluded i improvemet activities, ad their iput is cosidered i the selectio of improvemet priorities. Cosumer ivolvemet i quality activities should iclude: membership o the HIV quality maagemet committee, participatio o improvemet teams, review of performace data results, coordiatio of the cosumer advisory committee with the quality maagemet committee, ad implemetatio of specific improvemet activities aimed at improvig the quality of cliical care. Providers actively ecourage cosumers to participate as quality team members i learig etwork ad regioal group activities. orgaizatioal assessmets (oas) Developmet, implemetatio, ad spread of sustaiable quality improvemet (QI) throughout a HIV program require a orgaizatioal commitmet to the quality maagemet program, wherei structures, processes, ad fuctios support measuremet ad improvemet activities. Orgaizatioal ifrastructure is fudametal to QI success ad ivolves a receptive orgaizatio, sustaied leadership, staff traiig ad support, time for teams to meet, ad data systems for trackig outcomes. This structure supports quality iitiatives that apply robust process improvemet icludig: reliable measuremet, root cause aalysis, ad fidig solutios for the most importat causes idetified. The scorig structure measures program performace i specific domais alog the spectrum of improvemet implemetatio. The OA is implemeted i two ways: ) by a expert QI coach or ) as a self-evaluatio. The results are ideally used to develop a workpla for each elemet, with specific actio steps ad timelies to guide the plaig process ad focus o priorities, settig directio, ad esurig that resources are allocated for the quality maagemet program. Whether performed by a QI coach or applied as a self-evaluatio, key leadership ad staff should be ivolved i the assessmet process to esure that all key stakeholders have a opportuity to provide importat iformatio related to the scorig. Results of the OA should be commuicated to iteral key stakeholders, leadership, ad staff. Applied aually, this assessmet helps a program evaluate its progress ad guides the developmet of goals ad objectives. The OA tool is located i Appedix A. quality of care program stakeholders The AIDS Istitute Office of the Medical Director covees advisory committees of stakeholders to promote, moitor, ad support the quality of HIV cliical services for persos livig with HIV i New York State. The followig committees have bee established to provide expertise ad guidace to the Quality of Care Program. Quality Advisory Committee The Quality Advisory Committee provides the AIDS Istitute with expert advice regardig the developmet ad implemetatio of the Quality of Care Program. Sice 99, the Committee has met quarterly ad is composed of cliicias who represet HIV medical care cliics from all regios of the state, icludig Desigated AIDS Ceters, commuity health ceters, ad drug treatmet ceters. Cliicias the hiv quality of care program ew york state departmet of health aids istitute 6 7

6 with expertise i maagemet of sexually trasmitted ifectios (STIs) ad hepatitis are also members, alog with leaders of Rya White Part A service programs ad the Departmet of Correctios ad Commuity Services (DOCCS). The Quality Advisory Committee advises the Quality of Care Program o the selectio ad refiemet of cliical idicators that are aliged with cliical guidelies. I additio, the Committee offers guidace o performace review criteria, policy decisios, ad issues related to the quality of HIV care. Curret areas of focus iclude patiet retetio, viral load suppressio, coordiatio of care, STIs, adolescet trasitio ito adult care, ad the use of electroic health techologies ad regioal health iformatio orgaizatios (RHIOs) to geerate useful performace data. Cosumer Advisory Committee Iput from persos livig with HIV/AIDS is a itegral compoet of New York State s Quality of Care Program. The Cosumer Advisory Committee (CAC) was established i 00, ad its members represet the diversity of people livig with HIV/AIDS i New York State i terms of geography, geder, race, ethicity, disability status, socioecoomic status, ad exposure category. At quarterly meetigs, CAC participats discuss regioal quality of care issues from a cosumer perspective ad cosider strategies that ca effectively empower relatioships with providers. Key topics ad issues addressed iclude recommedatios for the creatio or revisio of HIV performace measures ad prioritizatio of statewide quality improvemet iitiatives. The committee also reviews cliical guidelies ad educatioal materials. To address the particular eeds of youg people livig with HIV/AIDS ad to gai their iput, the CAC helped to establish the Youg Adult Cosumer Advisory Committee i 008. Quality Advisory Committee ad CAC Joit Activities Together, the Quality Advisory Committee ad Cosumer Advisory Committee form a partership wherei each committee provides perspective ad isight ito quality of care ad idicator developmet. The close relatioship challeges the patiet-provider dichotomy that ofte hiders quality of care discussios. Recet joit Quality Advisory Committee ad Cosumer Advisory Committee activities iclude: The developmet of a ew idicator focused o patiet participatio i care plaig The update of STI measures to iclude iformatio o sexual history assessmet ad extrageital screeig The creatio of a subcommittee to address issues relevat to the deaf ad hard of hearig commuity The addressig of smokig cessatio as a joit edeavor NYC/Tri-Couty Part A Quality Maagemet Program Begiig i 000, the AIDS Istitute ad the New York City Departmet of Health ad Metal Hygiee established a partership to provide quality maagemet services to Part A fuded programs i the New York Eligible Metropolita Area (EMA). Because most of these programs provide HIV supportive care services i a variety of service categories, the Part A Quality Maagemet Program has developed distict approaches i workig with Part A providers ad the cosumers they serve. I the past two years, the Part A Quality Maagemet Program has developed ew quality idicators for each service category ad expects to use aual performace review data to accelerate improvemet. It also works to assist Part A providers i developig quality ifrastructure ad provides guidace ad support to sustai quality efforts by workig collaboratively to address the eeds of people livig with HIV/AIDS across the HIV care cotiuum. ADAP Quality Maagemet Program I New York State, over,000 people each year have access to lifesavig HIV medicatios through the AIDS Drug Assistace Program (ADAP). New York State employs a comprehesive prospective ad retrospective approach to cliical quality maagemet, icludig quarterly reviews of idividual ad pharmacy fillig patters to determie medically iappropriate or isufficiet regimes. Itervetios are iitiated with providers to improve patiet safety ad to modify regimes as required. Data collectio strategies iclude usig pharmacy ad primary care claims data to assess appropriateess of care. Quality of Care Workgroup The Quality of Care Workgroup comprises iteral AIDS Istitute stakeholders, icludig the Healthcare Divisio, the Office of the Medical Director, the Divisio of HIV/STD/Hepatitis C Prevetio ad Epidemiology, ad the Office of Medicaid Policy ad Programs. Meetig mothly, the workgroup discusses ad reviews all Quality of Care Program activities ad results, idetifyig opportuities for improvemet ad for icreased capacity buildig amog New York State HIV providers. Areas of focus iclude the developmet of processes to assist low-performig cliics i improvig the quality of care that they provide, developig ad refiig the Quality of Care Stadards, egederig peer learig opportuities through quality learig etwork activities, ad developig ad refiig quality of care campaigs ad special iitiatives. the hiv quality of care program ew york state departmet of health aids istitute 8 9

7 quality improvemet Sice 99, the AIDS Istitute has champioed the use of moder quality improvemet methods throughout the New York State healthcare delivery system. Providers are ecouraged to aalyze data ad assess the iteral factors that cotribute to orgaizatioal performace, ultimately reducig process variatio ad maximizig desired outcomes while workig to achieve measurable goals. Coachig ad Techical Assistace To build capacity ad capability for quality improvemet i HIV care, the Quality of Care Program offers coachig ad techical assistace to all New York State healthcare facilities. Workig with cliicias ad admiistrative staff, the AIDS Istitute quality coaches help HIV care providers to: Develop ad implemet sustaiable quality maagemet structures ad processes for ogoig iteral performace moitorig ad improvemet activities Measure performace data ad aalyze ad iterpret data results Cotiue their educatio i quality improvemet methods ad promote collaborative work of the healthcare team, icludig physicias ad patiets, i developig iovative improvemet strategies Quality of Care Program staff regularly review recet ehivqual ad Orgaizatioal Assessmet data from HIV providers to idetify programs to iform coachig eeds. HIV providers are also ecouraged to request assistace whe they recogize a eed for icreased quality maagemet capacity buildig. Programs with low scores across key idicators, such as viral load suppressio ad retetio, are give the highest priority. Those providers i eed of developig a HIV quality maagemet ifrastructure also receive high priority. Learig Networks ad Regioal Groups Adapted from the Istitute for Healthcare Improvemet s Breakthrough Series collaborative, regioal groups ad learig etworks combie ogoig quality coachig with structured oe-day or half-day group meetigs that focus o quality maagemet ad peer exchage. Regioal groups ad learig etworks are desiged to promote strategies to improve quality of care ad health outcomes by stregtheig provider ifrastructure ad icreasig competecy i performace measuremet ad quality improvemet methodology. This model provides a efficiet structure to covee groups of HIV providers o a ogoig basis, thereby facilitatig peer learig, sharig of improvemet activities, ad idetificatio of commo programmatic challeges. Regioal groups ad learig etworks also allow idetificatio of specific local priorities for improvemet ad foster coordiatio of cliical ad ocliical agecies i improvemet activities. NY Liks NY Liks regioal groups cosist of HIV cliical, service, ad prevetio providers withi a geographic area who, together with commuity members livig with HIV ad public health professioals, collaborate to ed HIV trasmissio ad HIV-related mortality. Usig moder improvemet sciece ad local epidemiological data, these groups aim to improve likage to ad retetio i HIV primary care, to optimize viral load suppressio, ad to improve both idividual ad commuity health outcomes. NY Liks regioal groups will reduce the trasmissio of HIV across New York State by: Implemetig a commuity-based respose to the HIV epidemic by mobilizig etworks of cliical ad ocliical providers, commuity leaders, ad commuity members livig with or affected by HIV/AIDS Aligig programs, providers, ad the commuity to address the goals of New York State to ed the HIV epidemic through shared local leadership ad with techical support from state ad local health departmets Buildig capacity for quality improvemet i the regio, idetifyig ad dissemiatig successful itervetios withi the cotiuum of HIV services, ad sustaiig the achieved regioal results Usig commuity-level data to lik public health strategies with cliic ad service-level improvemet iitiatives Performace Measuremet Performace measuremet ivolves the systematic process of data collectio to track patiet outcomes, thereby esurig that programmatic chages ca be data drive ad that ieffective solutios ca be idetified ad avoided. Performace measuremet also provides a method for moitorig improvemets ad establishig a baselie for performace comparisos across sites. Quality of Care Idicators The Quality of Care Program measures performace based o idicators that are liked to optimal cliical care outcomes. These specific aspects of cliical care are selected by the Quality Advisory Committee or subcommittees i cojuctio with the Cosumer Advisory Committee ad approved by the Medical Director as priorities for measurig quality i HIV care. Idicators are subsequetly developed ad reassessed i accordace with evolvig medical ad public health priorities. Some idicators apply to all persos livig with HIV, whereas others apply oly to specific populatio groups. A set of measures pertaiig to adolescet HIV care was developed i 00. the hiv quality of care program ew york state departmet of health aids istitute 0

8 ehivqual The Quality of Care Program measures performace usig data submitted through the web-based ehivqual applicatio. Lauched i 009 ad developed through support from the Health Resources ad Services Admiistratio HIV/AIDS Bureau (HRSA/HAB) ad HIVQUAL-US, ehivqual facilitates the collectio, aalysis, ad reportig of HIV cliical data accordig to cliical practice guidelies ad idicators developed by the AIDS Istitute ad its expert advisory committees. Performace data are submitted from over 00 healthcare facilities throughout New York State. Data collectio methodologies are based o well-established performace measuremet samplig tools ad are stadardized across all HIV facilities. The results of these reviews are istatly available through reports i the applicatio so that providers ca immediately use their data fidigs to prioritize upcomig quality activities. Each site also receives a idividualized report cotaiig its scores ad bechmarkig data from all New York providers. Data are aggregated to calculate mea scores ad percetiles, which are used to target providers for assistace ad cosultatio. The AIDS Istitute also regularly releases bechmarkig data reports that compare the quality of care across differet regios of New York State. Health Data NY As part of New York State s commitmet to trasparecy of data, the fialized ehivqual performace data report from HIV ambulatory care programs is available olie. For more iformatio, visit: Multi-Specialty Maiteace of Certificatio Portfolio Approval Program appedices the hiv quality of care program ew york state departmet of health aids istitute Physicias who are egaged i quality improvemet through the New York State Quality of Care Program may be eligible to ear twety poits of maiteace of certificatio (MOC) Part IV practice credit from their medical specialty board(s). This program offers a streamlied pathway to MOC that reduces redudacy ad champios leadership for improvemet implemetatio.

9 appedix a Orgaizatioal Quality Assessmet Tool This assessmet idetifies all of the importat elemets associated with a sustaiable quality maagemet program. purpose of the orgaizatioal assessmet Sustaied improvemet activities require attetio to the orgaizatioal quality maagemet program (QMP), i which structures, processes, ad fuctios support measuremet ad improvemet activities. Developmet, implemetatio, ad spread of sustaiable quality improvemet (QI) throughout a HIV program require a orgaizatioal commitmet to quality maagemet. Orgaizatioal ifrastructure is fudametal to QI success ad ivolves a receptive orgaizatio, sustaied leadership, staff traiig ad support, time for teams to meet, ad data systems for trackig outcomes. This structure supports quality iitiatives that apply robust process improvemet, icludig reliable measuremet, root cause aalysis, ad fidig solutios for the most importat causes idetified. This assessmet idetifies all of the importat elemets associated with a sustaiable QMP. Scores from 0 are defied to idetify gaps i the QMP ad to set program priorities for improvemet. The scorig structure measures program performace i specific domais alog the spectrum of improvemet implemetatio. Whe assigig a score of 0 for idividual compoets, the whole umber that most accurately reflects orgaizatioal achievemet i that area should be selected. If there is ay ucertaity i assessig whether performace is closer to the statemet i the ext higher or ext lower rage, the lower score should be chose. Scorig is desiged so that all items i a score must be satisfied to reach ay oe score for a compoet. Applied aually, this assessmet will help a program evaluate its progress ad guide the developmet of goals ad objectives. The OA is implemeted i two ways: ) by a expert QI cosultat or ) as a selfevaluatio. The results ideally will be used to develop a workpla for each elemet with specific actio steps ad timelies guidig the plaig process to focus o priorities, settig directio, ad esurig that resources are allocated for the QMP. Whether the OA is performed by a QI cosultat or applied as a self-evaluatio, key leadership ad staff should be ivolved i the assessmet process to esure that all key stakeholders have a opportuity to provide importat iformatio related to the scorig. Results of the OA should be commuicated to iteral key stakeholders, leadership, ad staff. Egagemet of program leadership ad staff is critical to esure buy-i across the program ad is essetial for traslatig results ito improvemet practice. A. Quality Maagemet goal: To assess the HIV program ifrastructure to support a systematic process with idetified leadership, accoutability, ad dedicated resources. Three compoets form the backboe of a strog, sustaiable quality program: leadership, quality plaig, ad a quality committee. leadership Seior leadership persoel are defied by each orgaizatio sice titles ad roles vary amog orgaizatios. Cliical HIV programs should iclude a cliical leader (medical director, seior urse) ad a admiistrative leader (program coordiator, cliic maager, admiistrative director). Larger programs may iclude additioal leadership positios. There may be other iformal leaders i the orgaizatio who support quality activities, but these are ot icluded i this sectio. Leaders establish a uity of purpose ad directio for the orgaizatio ad work to egage all persoel, cosumers, ad exteral stakeholders i meetig orgaizatioal goals ad objectives. This icludes providig motivatio that promotes shared resposibility ad accoutability with a focus o teamwork ad idividual performace. HIV program leaders should prioritize quality goals ad improvemet projects for the year ad should establish accoutability for performace at all orgaizatioal levels. The beefits of strog leadership iclude the clear commuicatio of goals ad objectives, wherei evaluatio, aligmet, ad implemetatio of activities are fully itegrated. Evidece of leadership support ad egagemet icludes the establishmet of clear goals ad objectives, the commuicatio of program/orgaizatioal visio, the creatio ad sustaimet of shared values, ad the provisio of resources for implemetatio. quality committee A quality committee drives implemetatio of the quality pla ad provides high-level comprehesive oversight of the quality program. This ivolves reviewig performace measures, developig workplas, charterig project teams, ad overseeig progress. Teams should be multidiscipliary ad iclude a cosumer whe feasible. Cosumer represetatio o the committee should be part of a formal egagemet process wherei cosumer feedback is solicited ad itegrated ito the decisio-makig process. The committee should have regularly scheduled meetigs, meetig otes to be distributed throughout the program, ad a committee chair or chairs. quality pla Quality improvemet plaig occurs with iitial program implemetatio ad aually thereafter. A quality maagemet pla documets programmatic structure ad aual quality team goals. The quality pla should serve as a road map to guide improvemet efforts ad should iclude a correspodig workpla to track activities, moitor progress, ad sigify achievemet of milestoes. the hiv quality of care program ew york state departmet of health aids istitute

10 A.. to what extet does seior leadership create a eviromet that supports a focus o improvig the quality of HIV care? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio Begiig implemetatio Implemetatio Progress toward systematic 0 Seior leaders are ot visibly egaged i the quality of care program. Leaders: are ot fully ivolved i improvemet efforts, quality meetigs, or providig resources for QI activities. are primarily focused o meetig exteral requiremets ad supportig compliace with regulatios. icosistetly use data to idetify opportuities for improvemet. Leaders: are ot egaged optimally. are egaged i quality of care with focus o use of data to idetify opportuities for improvemet. are somewhat ivolved i improvemet efforts. are somewhat ivolved i quality meetigs. support some resources for QI activities. Leaders: provide routie leadership to support the QMP. provide routie ad cosistet allocatio of staff or staff time for QI (depedig o facility size). are actively egaged i QI plaig ad evaluatio. actively maage/lead quality meetigs. clearly commuicate quality goals ad objectives to all staff. recogize ad support staff ivolved i QI. routiely review performace measures ad patiet outcomes to iform program priorities ad data use for improvemet. are attetive to atioal healthcare treds/ priorities that pertai to the program. Leaders: support developmet of a culture of QI across the program, icludig provisio of resources for staff participatio i QI learig opportuities, semiars, professioal cofereces, QI storyboards for distributio, draftig of scholarship, etc. support prioritizatio of quality goals based o data ad address critical areas of care i coordiatio with broader strategic goals for HIV care. promote patiet-cetered care ad cosumer ivolvemet through the QMP. are routiely egaged i QI plaig ad evaluatio. routiely provide iput ad feedback to QI teams. maagemet i place A.. to what extet does the HIV program have a effective quality committee to oversee, guide, assess, ad improve the quality of HIV services? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio Begiig implemetatio Implemetatio 0 Leaders: are actively egaged i the implemetatio ad shapig of a culture of QI across the program, icludig provisio of resources for staff participatio i QI learig opportuities, semiars, professioal cofereces, QI storyboards for distributio, draftig of scholarship, etc. ecourage ope commuicatio through routie team meetigs ad dedicated time for staff feedback. are routiely ad cosistetly egaged i QI plaig ad evaluatio. routiely ad cosistetly provide iput ad feedback to QI teams. ecourage staff iovatio through QI awards or icetives. directly lik QI activities back to istitutioal strategic plas ad iitiatives. A quality committee has ot yet bee developed or formalized or is ot curretly meetig regularly to provide effective oversight for the quality program. The quality committe: may review data triggered by a evet or problem, or geerated by door or regulatory urgig. has miimally itegrated quality activities ito other existig meetigs. The quality committe: has plas to hold regular meetigs, but meetigs may ot occur regularly ad/or do ot focus o performace data. has bee formalized, represetig most istitutioal disciplies. has idetified roles ad resposibilities for participatig idividuals. The quality committe: is formally established ad led by a program director, medical director, or seior cliicia. has implemeted a structured process to review data for improvemet. has defied roles ad resposibilities as codified i the quality pla. reviews performace data regularly, icludig staff ad cosumer satisfactio iformatio, if available. discusses QI progress ad redirects teams as appropriate. the hiv quality of care program ew york state departmet of health aids istitute 6 7

11 Progress toward systematic maagemet i place The quality committe: is formally established ad led by a program director, medical director, or seior cliicia specifically tasked with active oversight of the work of the quality program with established aual meetig dates. represets all disciplies. has established a performace review process to regularly evaluate cliical measures ad respod to results as appropriate, icludig staff ad cosumer satisfactio iformatio. commuicates with omembers through distributio of miutes ad discussio i regular staff meetigs. actively utilizes a workpla to closely moitor progress of quality activities ad team projects. provides progress reports to the orgaizatiowide quality program. The quality committe: is a formal etity led by a seior cliicia or admiistrator ad, where appropriate, is liked to orgaizatioal quality committees through commo members. has established a systematic performace review process, icludig cliical measures, cosumer satisfactio, ad operatioal measures to idetify aual goals. is resposive to chages i treatmet guidelies ad exteral/atioal priorities (NAHS, HAB, CMS) ad cosiders these i the developmet of idicators ad choosig improvemet iitiatives. has fully egaged seior leadership who lead discussios durig committee meetigs. effectively commuicates activities, aual goals, performace results, ad progress o improvemet iitiatives to all stakeholders, icludig staff, cosumers, ad board members. A.. to what degree does the HIV program have a comprehesive quality pla that is actively utilized to oversee quality improvemet activities? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio 0 A quality pla, icludig elemets ecessary to guide the admiistratio of a quality program, has ot bee developed. The quality pla: is writte with some of the essetial compoets ecessary to direct a effective quality program (see level ). may be writte for the paret orgaizatio or for the etwork, but plas specific to the HIV program or for the etwork have ot yet bee developed. Begiig implemetatio Implemetatio Progress toward systematic maagemet i place commets: The quality pla: is writte for the HIV program ad cotais some of the essetial compoets (see level ). is uder review for approval (if required by orgaizatio) by seior leadership ad icludes steps for implemetatio. The quality pla: reflects a effective HIV-specific quality program with all of the essetial QI compoets icludig: aual goals ad objectives roles ad resposibilities logistics performace measuremet ad review processes QI methodology commuicatio strategy cosumer ivolvemet program evaluatio procedure is routiely commuicated to program staff. icludes a aual workpla/timelie outliig key activities of the quality program ad improvemet iitiatives. The quality pla: has bee implemeted ad regularly used by the quality committee to direct the quality program. icludes aual goals idetified o the basis of iteral performace measures ad exteral requiremets through egagemet of the quality committee ad staff. icludes a workpla that is modified as eeded to achieve aual goals. is routiely commuicated to stakeholders, icludig staff, cosumers, board members, ad the paret orgaizatios, if appropriate. is evaluated aually by the quality committee to esure that the eeds of all stakeholders are met ad that chages i the healthcare ad regulatory eviromet are assessed to esure the program meets the chagig eeds of the HIV patiet. The quality pla: is writte, implemeted, ad regularly utilized by the quality committee to direct the quality program ad icludes all ecessary compoets (see level ). icludes regularly updated aual goals that were idetified by the quality committee usig data o iteral performace measures ad exteral requiremets through egagemet of the quality committee ad staff. icludes a workpla/timelie outliig key activities, is routiely ad cosistetly used to track progress o performace measures ad improvemet iitiatives, ad is modified as eeded to achieve aual goals. is aliged with that of the paret orgaizatio ad/or all etwork sites, as appropriate. the hiv quality of care program ew york state departmet of health aids istitute 8 9

12 B. Workforce Egagemet i the HIV Quality Program goal: To assess awareess, iterest, ad egagemet of staff i quality improvemet activities. Staff egagemet i quality activities at all orgaizatioal levels is cetral to QI success. This icludes developmet ad promotio of staff kowledge aroud orgaizatioal systems ad processes to build sustaiable quality maagemet programs, such as iteral maagemet processes, operatioal barriers, patiet iteractio, ad successful strategies ad barriers to QI implemetatio. Ogoig traiig ad retraiig i QI methodology ad practical skills reiforces kowledge ad the buildig of workforce expertise aroud QI. Traiig ad retraiig of staff ca be accomplished through formal sessios provided iterally by the orgaizatio or exterally through legitimate traiig resources such as the Natioal Quality Ceter (NQC). Traiig should be desiged to build capacity ad capability of the workforce based o regular assessmet ad reassessmet of staff kowledge ad skills. Such traiig ca be coducted o-site or off-site, durig ew staff orietatios, or as part of regular staff meetigs. As staff progress alog the cotiuum of QI sophisticatio, improvemet is slowly itegrated ito cliic practice, ehacig staff egagemet i the process. Immediate access to improvemet data, for example, empowers staff to focus o key areas of care ad build cosesus aroud QI activities to improve patiet outcomes. As QI becomes part of the istitutioal culture ad teamwork progresses, staff embrace their respective roles ad resposibilities, acquirig a sese of owership ad deeper ivolvemet i improvemet work. B.. to what extet are physicias ad staff routiely egaged i QI activities ad provided traiig to ehace kowledge, skills, ad methodology eeded to fully implemet QI work o a ogoig basis? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio Begiig implemetatio 0 Staff (cliical ad ocliical) are ot routiely egaged i QI activities ad are ot provided traiig to ehace skills, kowledge, theory or methodology, ad are ot ecouraged to idetify opportuities for improvemet or to develop effective solutios. Egagemet of core staff (cliical ad ocliical) i QI: is uder developmet ad icludes traiig i QI methods ad opportuities to atted meetigs where QI projects are discussed. Egagemet of core staff (cliical ad ocliical) i QI: is uderway, ad some staff have bee traied i QI methodology. icludes QI meetigs atteded by some desigated staff. Implemetatio Progress toward systematic maagemet i place Egagemet of core staff (cliical ad ocliical) i QI icludes: attedace i at least oe traiig sessio about QI methodology, ad staff members are geerally aware of QI activities (quality pla, priorities, etc.). ivolvemet i QI projects, project selectio, ad participatio i a QI committee. QI project developmet, wherei projects are discussed ad reviewed durig staff meetigs. defied roles ad resposibilities related to QI such that physicias ad staff are aware of the quality pla ad priorities for improvemet. a formal process for regularly recogizig staff performace i QI via performace appraisals, public recogitio durig staff meetigs, etc. Egagemet of core staff (cliical ad ocliical) i QI icludes: demostrated evidece that staff members are egaged ad ecouraged to use those skills to idetify QI opportuities ad develop solutios. a shared laguage regardig quality, which is evideced i routie discussio. a descriptio i the aual quality pla, ad icludes staff traiig ad roles ad resposibilities regardig staff ivolvemet i QI activities ad use i staff performace evaluatio. a formal process for recogizig staff performace iterally, ad QI teams are provided opportuities to preset successful projects to all staff ad leadership. Egagemet of core staff (cliical ad ocliical) i QI icludes: staff awareess of the importace of quality ad cotiuous improvemet ad their participatio i idetifyig QI issues, developig strategies for improvemet, ad implemetig strategies. regular ad cotiuous QI educatio ad traiig i QI methodology. leadership who ecourage all staff to make eeded chages ad improve systems for sustaiable improvemet, icludig the ecessary data to support decisios. formal ad iformal discussios wherei teamwork is opely ecouraged ad leadership shape teamwork behavior. routie commuicatio about ew developmets i QI, icludig promotio of QI projects both iterally (e.g., quality cofereces) ad exterally (e.g., related cofereces). opportuities for abstract developmet ad submissio to relevat professioal cofereces ad authorship of related publicatios about developmet ad implemetatio of istitutioal QMPs. the hiv quality of care program ew york state departmet of health aids istitute 0

13 B.. To what extet is staff satisfactio icluded as a compoet of the quality maagemet program? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio Begiig implemetatio Implemetatio Progress toward systematic maagemet i place 0 There is o mechaism i place to assess ad address staff satisfactio. Staff satisfactio: is assessed through iformal discussio with some staff. Staff satisfactio: is part of a formal process that icludes at least oe staff satisfactio survey. Staff satisfactio: is part of a formal process wherei iformatio is utilized to determie opportuities for improvemet. survey results are reviewed with staff, ad areas for improvemet are idetified. Staff satisfactio: survey results are reviewed with staff, areas for improvemet are idetified, ad plaig is uderway/work has begu to utilize this iformatio to improve work coditios withi the program. Staff satisfactio: is measured i multiple ways (surveys, performace reviews, etc.), ad iformatio is utilized to improve work coditios withi the ability of the program. survey results lead to improvemet projects or activities through fidigs, ad issues raised through staff feedback are prioritized i plas for improvemet. is characterized by staff-directed QI project teams that are iitiated based o data aalysis, with updates regularly commuicated to leadership ad all staff members. C. Measuremet, Aalysis, ad Use of Data to Improve Program Performace goal: To assess how the HIV program uses data ad iformatio to idetify opportuities for improvemet ad develops measures to evaluate the success of chage iitiatives, to alig iitiatives, ad to moitor program status, while esurig that accurate, timely data ad iformatio are available to stakeholders throughout the orgaizatio to drive effective decisio-makig. The Measuremet, Aalysis, ad Use of Data sectio assesses how the program selects, gathers, aalyzes, ad uses data to improve performace. This icludes how leaders coduct performace reviews to esure that actios are take, whe appropriate, to achieve program goals. C.. to what extet does the HIV program routiely measure performace ad use data for improvemet? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started 0 Performace measures have ot bee idetified. Plaig ad iitiatio Performace measures: have bee idetified to evaluate some compoets of the program, but do ot cover all sigificat aspects of service delivery. are defied ad used by persoel at some, but ot all, uits or sites. Performace data: collectio is plaed pedig iitiatio. Begiig implemetatio Performace measures: are exterally defied ad used by persoel at all applicable sites. Performace data: validatio, aalysis, ad iterpretatio of results o measures are i early stages of developmet ad use. results are occasioally shared with staff ad patiets. the hiv quality of care program ew york state departmet of health aids istitute Implemetatio (cotiued ext page) Performace measures: are exterally defied or required (e.g., HAB, HIVQUAL), with the itetio of meetig exteral regulatory requiremets ad the eeds of stakeholders, icludig patiets. are defied ad cosistetly used by persoel at all applicable sites. commets:

14 Implemetatio (cotiued) Progress toward systematic maagemet i place Performace data: are tracked, aalyzed, ad reviewed with the frequecy required to idetify areas i eed of improvemet, ad a structured review process is used regularly by the leadership to idetify ad prioritize improvemet eeds ad to iitiate actio plas to esure that goals are achieved. are collected by staff with workig kowledge of idicator defiitios ad their applicatio. results ad associated measures are routiely shared with staff, ad their iput is elicited to make improvemets. Performace measures: are exterally defied or required (e.g., HAB, HIVQUAL) ad tied to aual orgaizatioal goals, with the itetio of meetig exteral regulatory requiremets, the eeds of stakeholders ad patiets, ad the goal of aligmet with curret evidece i the diagosis ad treatmet of HIV. reflect priorities of cliic staff ad patiets, i cosideratio of local issues. Performace data: results ad associated measures are frequetly shared with staff to elicit their iput ad egage them i improvemet processes aliged with orgaizatioal goals. Performace measures: are selected usig orgaizatioal aual goals, with the itetio of meetig exteral regulatory requiremets as well as the eeds of stakeholders ad patiets, ad the goal of aligmet with curret evidece i the diagosis ad treatmet of HIV. reflect priorities of cliic staff ad patiets, i cosideratio of local issues. are defied for each program compoet ad actively used to drive improvemet activities. are evaluated regularly to esure that the program is able to respod effectively ad quickly to iteral ad exteral chages. Performace data: are visible or easily accessible to esure data reportig trasparecy throughout the cliic. are arrayed i formats that eable accurate iterpretatio, such as ru charts ad/or cotrol charts. results ad associated measures are systematically shared with all stakeholders, icludig staff, patiets, ad board members, to elicit their iput ad egage them i improvemet processes aliged with orgaizatioal goals. D. Quality Improvemet Iitiatives goal: To evaluate how the HIV program applies robust process improvemet methodology* to achieve program goals ad maitai high levels of performace over log periods of time. The Quality Improvemet Iitiatives sectio examies how leadership ad workforce use these methods ad tools to coduct improvemet iitiatives with emphasis o idetifyig the exact causes of problems ad desigig effective solutios, determiig program-specific best practices, ad sustaiig improvemet over log periods of time. I high-reliability orgaizatios, robust process improvemet methodology is routiely utilized for all idetified problems ad improvemet opportuities to esure cosistecy of approach by all staff members. *Robust process improvemet icludes reliably measurig the magitude of a problem, idetifyig the root causes of the problem, measurig the importace of each cause, fidig solutios for the most importat causes, provig the effectiveess of those solutios, ad deployig programs to esure sustaied improvemets over time. D.. to what extet does the HIV program idetify ad coduct quality improvemet iitiatives usig robust process improvemet methodology to esure high levels of performace over log periods of time? Each score requires completio of all items i that level ad all lower levels (except ay items i level 0). Gettig started Plaig ad iitiatio Begiig implemetatio Implemetatio 0 Formal quality improvemet projects have ot yet bee iitiated i the program. QI iitiatives: do ot iclude assessmet of orgaizatioal performace or system-level aalysis of data, are ot team based, ad do ot use specific tools or methodology. focus o idividual cases oly. use reviews primarily for ispectio. QI iitiatives: are prioritized by the quality committee based o program goals, objectives, ad aalysis of performace measuremet data. ivolve team leaders ad team members who are assiged by the quality committee or other leadership. are begiig to use specific tools or methodology to uderstad causes ad make effective chages. QI iitiatives: are ogoig based o aalysis of performace data ad other program iformatio, icludig exteral reviews ad assessmets. focus o processes of care i which QI methodology is routiely utilized. are regularly documeted ad provided to the quality committee. ivolve staff o QI teams, ad cross-departmetal/cross-fuctioal teams are developed depedig o specific project eeds. the hiv quality of care program ew york state departmet of health aids istitute