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QUALITY MANAGEMENT PLANS

Brazos Valley Council of GovernmentsJuly 2010

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THE BIG PICTURE: QM PLAN DIAGRAM

Annual QM Plan

Annual QM Goals

Work PlanExecution

Annual QM Program

Evaluation

Vision

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QUALITY MANAGEMENT PROGRAM

The term ‘Quality Management Program’ encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (e.g., committee structures, roles for stakeholders, providers and consumers) and quality improvement related activities (performance measurement, quality improvement projects and quality training activities).

Key Terms

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QUALITY MANAGEMENT PLAN

A quality management plan is a written document that outlines the HIV quality program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the program.

Key Terms

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REQUIREMENTS FOR A QUALITY MANAGEMENT PROGRAM

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QUALITY MANAGEMENT SYSTEMS REQUIRE…

The presence of a documented, ongoing quality improvement process (program description and plan of work)

A quality management committee function that includes member roles and responsibilities and documented minutes of each meeting

Significant participation by an M.D. in quality management functions

Evidence of actions to improve quality of care and services, including improvements in accessibility and availability of services

Data analysis in order to identify quality issues

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QUALITY MANAGEMENT SYSTEMS REQUIRE… Satisfaction surveys, follow up on all identified

issues identified in the surveys, and documentation of improvement of those issues

The identification of outcomes and efforts at improving them

Identification, monitoring and improvement of adverse outcomes

Corrective action plans for identified quality issues Program oversight and evidence of management

improvements, including revisions to program documentation, policies and procedures, committee actions and other quality initiatives

An annual evaluation of the quality management program

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QM PLAN COMPONENTS Quality Statement (Purpose) Measurable objectives for the QM program QM Committee Description (member roles, meeting

schedule, committee goals and activities) Activities for identifying quality issues and adverse

outcomes Method for analyzing and correcting quality issues

(e.g., PDSA model) Evaluating your QM program QM Work plan – a time table with steps needed to

implement your QM program

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QUALITY STATEMENTA brief mission statement describing the end goal of the HIV quality program to which all other activities are directed

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QM PROGRAM OBJECTIVES

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QM PROGRAM GOALS/OBJECTIVES

What you want to accomplish in your QM Program

The measures could be process or outcome oriented

Process measures are actions that are taken. A process measure could include an assessment of the number of patients with a completed medication adherence screen, the number of client files reviewed, or the number of no-shows to medical appointments.

Outcome measures are the results of care (e.g., the CD4 levels of patients on antiretroviral therapy)

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QM COMMITTEE MEMBERSHIP Diverse membership representing all areas of the

agency The quality management process should include

participation by representatives from agencies involved in the entire continuum of care, including: state and local governments; health, mental health, and social service providers; minority community-based agencies, community-based organizations, and persons with HIV infection. Additionally, these representatives may participate on the QM committee.

A physician is a member and has a significant interface with the QM process;

Documentation of member roles and responsibilities;

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QM COMMITTEE REQUIREMENTS Meets at least quarterly; Documentation of the process used to

identify quality issues with actions to analyze and correct them (e.g. Plan-Do-Study-Act);

Documentation of meetings that include attendance, agenda, meeting summary, material/information reviewed, issues/concerns identified and action taken; and

Documentation that shows QM Plan objectives are reviewed and evaluated at least quarterly.

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IDENTIFYING QUALITY ISSUESPerformance Measurement

Data Review

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IDENTIFYING QUALITY ISSUES

What are some ways that you identify quality issues?Performance measurement and data

reviewFeedback from staff and clientsClient complaintsChart reviewsCollection of client satisfaction information

(via surveys, suggestion box, etc)Notification from a hospital or other

provider of an adverse outcomeMonitoring reports from BVCOG or DSHS

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CLIENT SATISFACTION SURVEY PROCESS

Details of how the survey is developed, administered and evaluated annually;

Appropriately worded to elicit potential barriers to access, cultural competency, and quality (e.g. general satisfaction, client participation, perceived outcomes, continuity of care, effectiveness or result of service, timeliness of care, customer service/staff skills); and

Documentation of how results are used in the quality improvement process.

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A DOCUMENTED COMPLAINT PROCESS THAT INCLUDES:

Effective resolution of issues; Tracking of trends; and Description of how results of complaint trends

are used in the quality improvement process.

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METHOD FOR ANALYZING AND CORRECTING QUALITY ISSUES (e.g., PDSA model)

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EVALUATING YOUR QM PROGRAM

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EVALUATION: HOW WILL WE ASSESS THE QUALITY MANAGEMENT PROGRAM’S PERFORMANCE?

Infrastructure

QM Plan Elements: Evaluation

QI activities Performance measures

• Did we improve HIV care and services?

• Do we require further adjustment?

• Were goals met?• How effectively?

• Did work plan go as planned?

• Were established milestones hit?

• Were stakeholders informed?

• Was training provided?

• Are results in the expected range?

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TIPS FOR EVALUATION

Detail when and who is performing

the evaluation

Compare annual quality goals with year-end results

Use findings to plan next year’s activities; learn

and respond from past performance

Routinely use organizational

assessment tools

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WORK PLAN

Activities planned for the year to implement your program

Includes topics, people assigned, tasks, timeframes, steps taken/steps planned, dates completed

Should be an ongoing work plan that is updated regularly

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REFERENCES AND RESOURCES National Quality Center, Quality Academy

http://www.nationalqualitycenter.org/QualityAcademy/ Texas Department of State Health Services, AA Review

Tool http://www.dshs.state.tx.us/hivstd/fieldops/EvalTools.shtm

Institute of Medicine, Crossing the Quality Chasm: The IOM Health Care Quality Initiative, http://www.iom.edu/CMS/8089.aspx

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