2011 Quality Management Plan Wake Forest University Baptist Medical Center Infectious Diseases Specialty Clinic Ryan White Program

Transcription

1 011 Quality Management Plan Wake Forest University Baptist Medical Center Infectious Diseases Specialty Clinic Ryan White Program I. Wake Forest University Baptist Medical Center Mission: Wake Forest University Baptist Medical Center's mission is to improve the health of our region, state and nation by: 1. Generating and translating knowledge to prevent, diagnose, and treat disease. Training leaders in health care and biomedical science. Serving as the premier health system in our region, with specific centers of excellence recognized as national and international care destinations II. Quality Statement The overall goals of the Quality Management Program at the WFUBMC Infectious Disease Specialty Clinic Ryan White Program (IDSC-RWP) are: 1. To ensure that all patients are receiving HIV medical care governed by clinical standards of care that are established, maintained, and revised by the U.S. Department of Health and Human Services, the United States Centers for Disease Control (CDC), the Infectious Diseases Society of America (IDSA), the International AIDS Society of the United States of America (IAS-USA), and the North Carolina State Department of Health and Human Services.. To continuously improve the processes and systems that influence patient health outcomes. In keeping with the institution s mission statement, the IDSC-RWP practices continuous measurement, maintenance, evaluation and improvement of health care standards for all patients. The IDSC-RWP utilizes Clinical Quality Assurance and Continuous Quality Improvement (CQA/CQI) principles and methodologies as a basis for the monitoring and improvement of care and services. By identifying opportunities for improvement, collecting and analyzing data, developing and implementing plans, and subsequently evaluating those plans, the IDSC-RWP can fulfill its mission of provision of quality healthcare to all patients with continuos improvement of the processes and systems that influence patient outcomes. The IDSC-RWP Quality Management Program is consistent with the organization-wide approach to quality improvement at WFUBMC. III. Quality Infrastructure The IDSC-RWP Quality Management Program is made up of an extensive Clinical Quality Assurance (CQA)/Continuous Quality Improvement (CQI) Framework which

2 IDSC-RWP 011 Quality Management Plan Page of 1 provides comprehensive and ongoing CQA/CQI activities related to all clinic programs and services. There is a CQA Program in place which all IDSC-RWP staff participate in and a CQI Program which implements performance improvements through annual CQI projects throughout the clinic, led by an interdisciplinary CQI Committee. The IDSC- RWP Quality Management Program is led by the IDSC-RWP Medical Director and Clinical Quality Administrator, under the oversight of the Section Head of the Section on Infectious Diseases. Clinical Quality Assurance Program The Clinical Quality Assurance Program (CQA) is comprised of comprehensive medical chart review and corresponding monthly Clinical Quality Assurance reporting during monthly meetings attended by all IDSC-RWP staff. The CQA program is run by the IDSC-RWP Medical Director and Clinical Quality Administrator, with the assistance of clinical staff to conduct the monthly chart reviews. Additionally, a quality assurance review of medical case management charts from subcontracted case management agencies will be conducted by the Grants Quality Administrator, as part of our Ryan White Part B Region III Network of Care program requirements. Medical Chart Review The IDSC-RWP Medical Director and Clinical Quality Administrator will be responsible for maintaining the medical chart review program and assigning staff on a rotating basis to assistance in the review. Medical chart reviews are conducted on a monthly basis. All new patient charts for the month are included in the review as well as a sample of ongoing patient charts. The average number of records to be reviewed each month is 50. Each chart is reviewed for quality assurance measures in the following categories: Medical Management; s and Vaccines; Laboratory Testing; Ancillary/Supportive Services; and Medical Case Management (if enrolled). A description of particular clinical indicators evaluated within each can be found in Section IV. A sample of the chart review form can be found in Appendix I. For the pediatric HIV patients, a quarterly chart review of all patient charts will occur, using the clinical indicators identified in Section IV. A sample of the chart review form can be found in Appendix II. Clinical Quality Assurance Monthly Reporting The Clinical Quality Administrator will generate a monthly report summarizing CQA chart review activities to be presented at the monthly IDSC-RWP staff meeting. Areas for improvement are discussed and feedback solicited from all disciplines to encourage a team-based approach to enhancing HIV service delivery. Year to date statistics for clinical indicators being tracked and trended are also provided.

3 IDSC-RWP 011 Quality Management Plan Page of 1 Medical Case Management Quality Assurance Review For patients enrolled in medical case management, the Grants Quality Administrator will be responsible for conducting semiannual chart reviews at the subcontracted Ryan White Part B case management agencies. A sample of charts will be requested from each agency and documentation reviewed for completeness and client eligibility for medical case management. Each agency will receive a report of any findings and deficiencies needed to be addressed. Subcontracted agencies with major discrepancies in the provision of services may be given notice of the cancelation of the subcontract or be placed on a probationary period for three months, with monthly technical assistance site visits to be conducted during that time (or until all issues/problems are resolved). Continuos Quality Improvement Program CQI Program Overview The Continuous Quality Improvement Program (CQI) is run by an interdisciplinary CQI committee, comprised of IDSC-RWP staff members. Committee members evaluate and determine quality standards, annual Quality Management Goals and indicators to track, collect and manage data, disseminate information, and follow-up consistently on quality management and outcomes. They are also responsible for the development and execution of an annual CQI project. Committee Structure The overall responsibility and leadership for the CQI Program lies with the Chief of the Section on Infectious Diseases and the IDSC-RWP Medical Director, who authorizes the CQI Committee to plan, assess, measure, and implement performance improvements throughout the program. Under their direction, the Clinical Quality Administrator is responsible for the facilitation of all CQI Committee activities as Team Leader. The membership of the CQI Committee reflects the diversity of disciplines within the IDSC-RWP. The CQI Committee consists of staff members representing all different departments at the clinic and members have assigned roles and responsibilities as follows: The Team Leader is responsible to manage the CQI Committee in order to effectively carry out its goals and objectives, as well as edit and assemble all reports and written materials related to the project for review by committee members, key stakeholders, the Chief of the Section on Infectious Disease, WFUBMC Administration and relevant departments, as well as the HRSA, the North Carolina State Department of Health and Human Services, and other funders. The Team Facilitator works directly with the Team Leader to plan meetings, develop agendas, collect and analyze data and written materials, and tend to the meeting process. This includes ensuring that everyone is in

4 IDSC-RWP 011 Quality Management Plan Page 4 of 1 attendance and participating, helping to keep participants on track with the agenda and project process, and recording meeting minutes/summaries. Each individual reflects the range of functions and departments involved in the process being improved in order to build and maintain consensus from key individuals on the solutions to the problems. They have intimate knowledge of the process, personal involvement, and vested interest in the provision of quality HIV services at the clinic. The committee is comprised of the following staff members: Staff Member and Title Discipline CQI Committee Role Aimee Wilkin, MD, MPH Administration/ CQI Program Oversight IDSC-RWP Clinic Director/Ryan White PI Medicine Jennifer Keller, MPH Administration Team Leader Clinical Quality Administrator Michelle Chester Administration Team Facilitator Program Assistant Richard Wooldredge, MA Administration Grants Quality Administrator Amy Fenstemaker Support Services Patient Navigator Clavenda Canty Support Services Patient Navigator John Haworth, MSW Support Services Social Worker John Switzer Information Health Information Technology Coordinator Technology Kristen Lankford Support Services Financial Counselor Bonnie Cochran Information Data Coordinator Technology Cindy Patrick, RN Nursing Triage Nurse Mildred Horning, RN Nursing Triage Nurse Jim Augsburger, RN Infection Control HIV Coordinator Jim Johnson Pharmacy Pharmacist John Williamson Pharmacy Pharmacist Luis Barroso, MD Medicine Attending Physician Miriam Patterson Medicine Physician Assistant Rachel Miller Physician Assistant Medicine Infectious Disease Fellow (rotating basis) Medicine Committee structure may be altered on an ad hoc basis as needed and additional memberships may be established as needed.

5 IDSC-RWP 011 Quality Management Plan Page 5 of 1 Annual CQI Project The CQI Committee will undertake an annual CQI Project to be determined based on analysis of IDSC-RWP needs and areas of improvement that have been identified through such mechanisms as performance measurement review statistics, information gathered from Client Satisfaction Survey, and CAB meeting minutes and member feedback. These needs and areas of improvement will be identified through ongoing evaluation activities, chart reviews, feedback from site visits, and other CQA mechanisms. For each CQI Project, the CQI Committee is responsible for using established CQI mechanisms such as the Plan-Do-Study-Act (PDSA) model to analyze, design, implement, and evaluate changes for clinic performance improvement. Once a project is selected, the CQI Team will take on the responsibility of developing a project plan with action steps and target completion dates. Each CQI Project should be a vehicle by which the CQI Team addresses the annual quality goals set forth in the IDSC-RWP Quality Management Plan. Meeting Frequency The CQI Team will have at least 10 scheduled meetings per year, with additional meetings called as needed during the project periods. Minutes of meetings will be kept and reviewed by team members at each subsequent meeting. A written summary of the meeting will routinely be made available to staff at the monthly IDSC-RWP staff meetings and consumers at the monthly Consumer Advisory Board meetings. Evaluation and Follow-Up on Committee Findings The CQI Committee will present its annual CQI project to the Section on Infectious Diseases as well as the members of the Consumer Advisory Board. Evaluation will be requested from those present and feedback will be analyzed by the CQI Committee members for implementation of recommended process improvements as well as be incorporated into the next CQI project and team activities. Data Management IV. Performance Measurement WFUMBC and the IDSC-RWP maintain health information in an electronic medical record system called Centricity for outpatient records and Carecast for inpatient records. These systems interface for coordination of care. Client data is gathered from these systems for the purposes of required reporting, approved research, and CQA/CQI activities. Additionally, the IDSC-RWP uses CAREWare software for collecting clientlevel data and generating reports required by the Ryan White Program. Client-level data includes medical information as well as medical case management information and activities recorded and entered into CAREWare by subcontracted agencies for patients enrolled in medical case management.

6 IDSC-RWP 011 Quality Management Plan Page 6 of 1 Clinical Performance Indicators In accordance with the CQA program outlined previously, the IDSC-RWP will review a sample of medical charts on a monthly basis to determine compliance with standards of care. As stated, in Appendix I and II, the chart review forms can be found which outline the data elements to be reviewed. Summary results of these reviews will be tracked and trended monthly and reported at the monthly IDSC-RWP staff meeting. Clinical performance indicators tracked through the medical chart reviews are drawn from the HRSA HAB HIV Core Clinical Performance Measures for Adult/Adolescent Clients (April 009 version) as well as internal program priorities for the pediatric HIV program. The charts below lay out the key service areas and accompanying performance indicators for adult and pediatric patients tracked by the IDSC-RWP in the CQA program. Each indicator is assessed annually for all patients who complete an initial comprehensive medical exam and those ongoing patient charts selected for review during that month. Service Areas Medical Management Testing/ s/ Vaccines Corresponding Performance Indicators HAART Adherence Assessment and Counseling HIV Risk Counseling Adult Patient Clinical Performance Indicators Definition Provision of Antiretroviral therapy for patient with a history of an AIDS-defining illness, with CD4 count <50 (011 Guidelines), or by Physician recommendation Assessment and counseling for ARV adherence for patients with HIV infection and on ARV medications two or more times in the past 1 months Assessment and counseling on HIV-transmission risk behaviors ( Prevention with Positives ) one or more times in the past 1 months Patient with CD4 T-cell count <00 in the past 1 months prescribed Pneumocystis pneumonia (PCP) Prophylaxis Patient with CD4 count <50 in the past 1 months prescribed Mycobacterium avium Complex (MAC) prophylaxis HAB HIV Core Clinical Performance Measures for Adult/Adolescent Clients Group N/A PCP 1 Prophylaxis MAC Prophylaxis ARV Therapy Provision of ARV therapy for pregnant women 1 for Pregnant Women Medical Visits Completion of or more medical visits with the HIV provider in 1 the past 1 months Oral Exam Completion of annual oral exam by a dentist in the past 1 months TB Documented PPD testing for patients who have not had documented culture-positive TB disease or previous documented positive TST or IGRA since initial diagnosis Hepatitis B Vaccination Hepatitis C Receipt of Hepatitis B Vaccination series to prevent infection for documented HBV negative patients Hepatitis C antibody test performed for documented HCV negative patients at least once since initial diagnosis

7 IDSC-RWP 011 Quality Management Plan Page 7 of 1 Medical Case Management Hepatitis C Treatment Cervical Cancer Influenza Vaccine Pneumococcal Vaccination Mental Health Substance Use Tobacco Cessation Counseling Chlamydia Gonorrhea Hepatitis C quantitative RNA performed for all HCV positive patients with referral to Co-ID clinic Female patient with documented Pap screening results in the past 1 months Receipt of Influenza vaccine for patients able to receive vaccine in the past 1 months Receipt of Pneumococcal vaccine for patients able to receive vaccine since initial diagnosis Receipt of annual Mental Health and Assessment in the past 1 months Receipt of screening for substance abuse (alcohol and drugs) for patients who have had a medical visit within the past 1 months Patient has received tobacco cessation counseling if using tobacco products within the past 1 months Documented Chlamydia test within the past 1 months for patients who had a medical visit and were newly enrolled in care; sexually active; and/or had a STI within the last 1 months Documented Gonorrhea test within the past 1 months for patients who had a medical visit and were newly enrolled in care; sexually active; and/or had a STI within the last 1 months Lipid Documented Lipid in the past 1 months Syphilis Documented Syphilis in the past 1 months 1 CD4 Count or more CD4 T-cell counts performed at least month apart in n/a the past 1 months HIV Viral Load Count or more HIV Viral load counts completed at least months apart in the past 1 months Toxoplasma Patient has received a toxoplasma screening at least once since n/a initial diagnosis Pediatric Patient Clinical Performance Indicators Performance Indicators Definition TB Documented referral for annual PPD skin test to Primary Care Physician or Health Department Immunizations Documentation of referral to Primary Care Physician for all childhood vaccines, pneumococcal vaccine, and annual flu vaccine HIV Phenotype HIV Phenotype profile completed on every new patient (if viral load is >1,000 copies/ml) and/or patients failing on current ART regimen Oral Health Documentation of referral for an annual dental exam CD4 Count CD4 count monitoring completed quarterly in the measurement year HIV Viral Load Count HIV viral load monitoring completed quarterly in the measurement year Gynecology Documented referral to Gynecologist for adolescents who are sexually active Neurodevelopmental Evaluation Documented referral to a neurodevelopmental evaluation to identify HIV-related encephalopathy, developmental delay, and behavioral disorders Psychological Evaluation Documented referral to onsite Psychologist for evaluation for perinatally infected children and their families

8 IDSC-RWP 011 Quality Management Plan Page 8 of 1 V. Ongoing Quality Priorities and Annual Quality Goals To ensure that the IDSC-RWP Quality Management Program fulfills its overall mission of provision of quality healthcare to all patients which is continuously being evaluated in order to improve the processes and systems that influence patient outcomes, the following ongoing priorities and 011 annual goals have been established: Ongoing Priorities The following list represents the ongoing priorities for the IDSC-RWP Quality Management Program. These priorities encompass the foundational goals of the program and provide the basis for its development and maintenance: Establish an organizational structure within the IDSC-RWP that supports CQA/CQI. This includes but will not be limited to: membership, frequency of meetings, roles and responsibilities, resources, and reporting systems. Update standards of care as set forth by the U.S. Department of Health and Human Services, the United States Center for Disease Control (CDC), the Infectious Diseases Society of America (IDSA), the International AIDS Society of the United States of America (IAS-USA), and the North Carolina State Department of Health and Human Services. Track and trend clinical quality of care indicators monthly to ensure standards of care are being met for all IDSC-RWP patients through randomized chart review of at least 500 new patient and ongoing patient records per year. Identify set of specific clinical quality of care indicators to track annually for all patients receiving medical care at the IDSC to identify areas of need for CQI opportunities. Educate IDSC-RWP Staff about CQA/CQI methodologies and techniques through training sessions offered by the National Quality Center, TARGET Center, Southeast AETC, and other training organizations. Facilitate the active involvement of IDSC-RWP staff in the Quality Management Program. Ensure that CQA/CQI activities are routinely conducted, documented, and reported to continuously improve the quality of care and services. Facilitate communication among WFUBMC s Administration, School of Medicine, IDSC-RWP staff, Consumer Advisory Board, and other relevant stakeholders on findings, conclusions, actions, and resolution of performance improvement issues. 011 Annual Goals For 011, we will focus on achievement of a set of goals in the areas of Clinical Performance and Consumer Involvement.

9 IDSC-RWP 011 Quality Management Plan Page 9 of 1 Clinical Performance Increase access to appropriate, quality, specialized medical care through the following clinical outcomes: 011 Adult Clinical Performance Measure Goal For all female patients seen in 011, 75% will have a Pap screening conducted by an IDSC Provider or gynecological provider of their choice within the measurement year. For all new patients seen in 011, 95% will receive an initial Mental Health and Assessment. For all patients who are using tobacco products, 90% will receive tobacco cessation counseling within the measurement year For all patients who are sexually active, 90% will undergo STD screening in the measurement year (Syphilis, Chlamydia, Gonorrhea, Trichomoniasis) For all patients seen in 011, 95% will have documented Hepatitis C screening at least once since initial diagnosis 011 Region III Network of Care Medical Case Management Performance Measure Goal For all patients enrolled in medical case management, 75% have a medical case management care plan developed and/or updated at least times in the measurement year 011 Part D Pediatric Program Performance Measure Goals Provide or obtain confirmation of completion of all pediatric immunizations for 95% of patients Provide or obtain confirmation of annual PPD skin test completed with result documented for 90% of patients Confirm receipt of annual oral health exam for 85% of patients 007 National HIVQUAL Benchmarks Top 10%: 100% Top 5%: 89.% Mean: 70.8% Top 10%: 100% Top 5%: 84% Mean: 4% Top 10%: 100% Top 5%: 100% Mean: 8.8% N/A Top 10%: 100% Top 5%: 100% Mean: 90.9% 007 National HIVQUAL Benchmarks N/A 007 National HIVQUAL Benchmarks N/A Top 10%: 100% Top 5%: N/A Mean: 69.7% N/A Consumer Involvement Revise system of consumer involvement through the following initiatives: Consumer Involvement Goals Provide the IDSC-RWP Consumer Advisory Board with an update of all CQA and CQI activities at each meeting for 011 Allow a member of the IDSC-RWP Consumer Advisory Board to attend the monthly staff meeting once each quarter to provide staff with a comprehensive update of the CAB s activities and feedback on program performance from members Create an IDSC-RWP-specific patient satisfaction survey and solicit feedback from patients at least once annually Recruit a member of the CAB to join the IDSC-RWP CQI Committee Conduct quarterly patient education events where CQA/CQI activity information is distributed to the larger patient population as well as provide educational programming to increase consumer health literacy

10 IDSC-RWP 011 Quality Management Plan Page 10 of 1 VI. Participation of Stakeholders Consumers The IDSC-RWP recognizes that patient involvement in program planning and development is essential. Furthermore, we strive to provide unique and appropriate educational opportunities for our patients. Consumers have the opportunity to be updated on findings and work being done related to CQA/CQI in their Consumer Advisory Board meeting, which occurs every month. The meeting is attended by one of the IDSC-RWP staff members on the CQI Team, which will ensure that information related to Quality Management is being passed on to consumers. Additionally, there are specific quality goals for 011 directly related to enhancing consumer involvement in relation to IDSC-RWP Quality Management activities. Institution One of the ongoing priorities for the Quality Management Program at the IDSC-RWP is to involve staff actively in the Quality Management Program and its continuous quality improvement activities. All staff members participate in CQA and the membership of the CQI Committee reflects the diversity of disciplines within the IDSC-RWP, with at least 1 representative from each area. Participation in Quality Management is part of all employee job expectations. Findings from CQA/CQI activities as well as summary reports of quality improvement committee meetings will be shared with staff to ensure open communication flow within the Quality Management program. Ongoing training on Quality Management principles will be provided for all staff. WFUBMC s Administration, School of Medicine, IDSC-RWP staff, Consumer Advisory Board, and other relevant institutional stakeholders are updated on findings, conclusions, actions, and resolution of performance improvement issues. Funders Additionally, grant funders (HRSA, North Carolina State Department of Health and Human Services, KBR, and Adam Foundation) are given information related to all CQA/CQI activities in quarterly/annual reports as well as data submission through the annual Ryan White Data Report, Ryan White Services Report, and HIVQUAL, as well as during site visits. VII. Evaluation of Quality Management Program The CQI Committee will be responsible for conducting an annual evaluation of the Quality Management Program. This evaluation will look at the program as a whole, evaluating its strengths, weaknesses, and identifying any challenges to conducting its activities over the year. Improvements to the program structure will be made as needed. Additionally, the CQI Committee will be responsible for selecting annual indicators with established performance goals for the quality assurance component of the Quality Management Program.

11 IDSC-RWP 011 Quality Management Plan Page 11 of 1 Appendix I Appendix II Appendix II

12 IDSC-RWP 011 Quality Management Plan Page 1 of 1 Appendix II