QUALITY IMPROVEMENT PROGRAM Mounta in Counties CARE & Case Management Program s Mission: The organizationa l mission of the Mountain Counties HIV CARE & Case Management Programs is to promote high quality HIV related patient care, support services, and education within four HIV clinic sites. I. Purpose: The purpose of the Quality Manage ment Plan of the Mountain Counties HIV CARE & Case Management Programs is to establish a coordinated approach to address quality assessment and process improvement. The mission statement of the Mountain Counties HIV CARE & Case Management Programs is listed in the previous paragraph, and the goals and objectives for quality improvement are outlined below. II. Goals and Objectives: The goal of the Mountain Counties HIV CARE & Case Management Programs is to address quality assessment and performance improvement in the clinical, administrative and programmatic areas that include: Clinical care Patient and staff education Continuity of care Patient satisfaction Case management Medical records / data collection Programmatic requirements for Part C The objectives for this goal include: A. Develop a p lanning mechanism: Data is to be collected from internal and external sources on a quarterly basis. These sources include, but are not limited to: client level clinical and utilization data, financial data, input from leadership and line level staff, the consumer advisory council feedback and ARIES data. Clinical, operational and programmatic aspects of care will be revi ewed utilizing data quarterly, following the quarterly HIV clinics. B. Address d esign needs: patient care scheduling, access to care, service delivery sys tem changes, and supportive services that impact on the overall quality and satisfaction with care will all be reviewed to assess the design of services both new and existing. C. Refine data capabilities: data collection will help to identify trends in care, clients lost to care, and overall utilization of services and adherence to Parts B & C work plan s. Regular review of data for performance measures will occur on a quarterly basis in conjunction with CQI meetings. Data sources will include, but not be limited to: clinical measures, demographic data, patient satisfaction surveys, visit frequency and missed appointment data, case management surveys, and other ARIES data as indicated.
D. Initiate a ssessment procedures : Assessment and evaluation of data will be performed by the CQI committee and other staff as appropriate. These procedures will determine how well services are delivered, and to determine where new opportunities might exist for improvement in individual or overall programmatic issues. E. Focus on improving quality : in all of its dimensions by utilizing multidisciplinary, data driven, team (including consumer advisory council) approaches to problem solving. F. Promote communication: All improvement plans will be communicated to staff and consumers as appropriate. Meetings, e-mails, memos, informal verbal communications are considered appropriate methods to spread the word about the committee s activities and findings, analyses, actions and evaluations regarding quality improvement recommendations and improvement plans. G. Establish collaborative relationships : for the purpose of collectively promoti ng the welfare of the community the grantee will continue to nourish the relationships developed with other community agencies involved in the overall care and support of persons living with HIV disease. New relationships will be established as needed ad appropriate for the improvement of care and services. III. Structure A. Framework Authority: The Ryan White Part C Medical Director and the Part B & C Project Coor dinator are responsible for the planning, direction, coordination and improvement of health care services in the Mountain Counties HIV CARE & Case Management Programs. This key administrative leadership group approves the quality improvement plan and reviews quality improvement activities throughout the year. They participate on the commit tee in their roles as clinician and administrator as well. Under this leadership a Continuous Quality Improvement (CQI) committee has been formed. Committee Structure: This committee consists of the leadership group, the patient care coordinators fro m each of the four clinic sites, and if possible, a representative from each ind ependent clinic s CQI committee. Meetings are held four times a year, and specific indicators for review and improvement are identified at the first meeting of the new fiscal year. Outcome measurements are consistent with P ublic Health Service guidelines for HIV care and prevention of Opportunistic Infections, and programmatic indicators are consistent with the four HRSA principals to eliminate barriers to care, eliminate health disparities, assure quality and improve public health. CQI Committee activities are reported to existing quality committees from each of the four clinic sites. These committees oversee, prioritize and direct planning, design, measurement, assessment and improvement of organizational performance. The EIS CQI activity is then incorporated into these more global committee structures.
Other Quality Activities: The Ryan White Part B & Part C Project Coordinator will participate in the Northern California Regional Quality Group, facilitated by National Quality Center staff. The purpose of a Regional Quality Group is to provide a forum to promote group learning among HIV care providers who share a commitment to improving the care they provide to their patients. A group forum provides an opportunity for an exchange of ideas and best practices and fosters peer learning. The primary goals of the Regional Quality Group are to: Provide guidance and technical assistance to Ryan White Part C and Part D funded programs in quality infrastructure, performance measurement and quality activities Assist participants in understanding HRSA's requirements regarding quality management Promote successful methodologies and best practices Create a forum for ongoing networking among grantees Consumer Advisory Council A consumer advisory council (CAC) was established to provide input in to quality improvement activit ies and participate in projects as appropriate. The CAC meets three times a year, in conjunction with the Mountain Counties HIV/AIDS Advisory Council, which serves as the advisory body for all the Mountain Counties HIV CARE & Case Management Programs, including Part C & Part B/HCP. B. Content The Mountain Counties Part C & Part B/HCP Programs are designed to address Quality Assessment and Performance Improvement in the following functional areas and important or programrequired aspects of care: Clinical Primary Care Case Management Services Patient and staff education Continuity of care Patient satisfaction Medical record / data collection Clinical Data Entry Adherence to federal workplans Special attention will be given to areas with external regulatory requirements. C. Data Collection Plan
Performance measures will be selected for the major areas of care. Regular review of performance measures will occur acco rding with the scheduled CQI committee meetings, and on an ongoing basis for programmatic monitoring. The Program Coordinator will be responsible for overseeing these activities. Data sources will include, but not be limited to: Clinical measure s based on DHHS guidelines for care of the HIV infected adult, using HIVQual and HAB Core Measures. Clinical data measures using ARIES and based on established HIV care guidelines. Patient satisfaction surveys Demographic data, missed appointment data, visit frequency data from established data collection system Data will be collected using appropriate sampling methodology and include current and retrospective reviews. D. Multidisciplinary and Development of Plan for improvement When an opportunity for improvement is identified, CQI committee members will work with clinic staff to develop improvement plans. These teams will include staff members closely associated with t he process or area under study, and staff members from other departments impacted by the improvement process. This inclusive process will help to promote improvement and collaborative relationships. E. Communicating with Stakeholders All CQI activities will be reported to the appropriate departments, existing quality committees and regulatory agencies relative to the structure of the Mountain Counties HIV CARE & Case Management Programs. Additionally, they will be reported to the Part C Project Officer on an on-going basis. All Improvement Plans will be communicated to staff at clinic meetings, and at specific departmental meetings as appropriate. Meetings, memos, verbal communications and demonstrations are all acceptable methods of communicating the team s activities and improvement plans. The Quality Plan and associated indicators will be reviewed and updated annually. F. Sustaining Improvements
Once an improvement plan has been implemented, it will be monitored to determine whether it remains successful over time. Prior plans will be reviewed and reported on at each quarterly CQI committee meeting until such time as they are deemed fully incorporated and successful. The schedule for monitoring will follow the activity schedule of the CQI Committee. G. Assessment and Evaluation: Assessment and evaluation of the collected data will be performed by the CQI committee. This team will determine if the data warrants further evaluation. This ongoing review process will help to establish priorities and identify opportunities for improvement. Leadership group signatures: Mark Satterfield, MD Ryan White Part C Medical Director Andrew Woodruff Ryan White Part B & C Project Coordinator