section 4 processes & projects section 1 quality statement section 2 quality infrastructure...
TRANSCRIPT
Section 4
Processes & Projects
Section 1
Quality Statement
Section 2
Quality Infrastructur
e
Section 3
Performance Measures &
Annual Goals
Section 7
Communicating Reports & Initiatives
Section 6
Stakeholder Participation
Section 5
Yearly Program Activities
Section 8
Evaluation
Writing a Quality
Management Plan
GlossaryCredits/Contact
Quality Statement
Description
Additional Resources
Tips and Tools
Example
The quality plan begins with a quality statement. It should include a brief
purpose statement describing the end goal of your HIV quality program and a
shared vision to which all other activities are directed.
Assume an ideal world and ask yourself, “What do we want to be for our
clients and our community?”
Quality Statement
Description
Additional Resources
Tips and Tools
Example
Quality statements should:
• Be brief
• Be visionary
• Include internal and external expectations
• Make references to Ryan White legislative requirements for quality
management
Quality Statement
Description
Additional Resources
Tips and Tools
Example
Click to open
Description
Additional Resources
Tips and Tools
Example
Additional Resources for Writing QM Plans
• National Quality Center (NQC) Quality Academy:
The Quality Management Plan (lesson 5)
• NQC Resources:
How to develop and update written quality management plans
• Health Resources and Services Administration:
Developing and implementing a QI plan
Quality Statement
Quality Infrastructur
e
Description
Additional Resources
Tips and Tools
Example
Quality infrastructure includes the critical aspects of funded services.
These should be relevant, measurable, and improvable. If available, you will
want to include:
• Leadership: those responsible for QM initiatives
• Quality committee structure: those who serves on the QM committee
as chair and or as coordinators
• Standards: the framework and expectations for the QM program
• Roles and responsibilities: key persons, organizations, major
stakeholders
• Resources: resources available/used by the QM program
• Capacity building: how quality is being integrated into all
functions/aspects of the program
Quality Infrastructur
e
Description
Additional Resources
Tips and Tools
Example
The quality infrastructure section of the quality plan should include:
• 3 – 5 pages
• Job Functions
• All stakeholders and responsibilities
• Linkages/networks
Quality Infrastructur
e
Description
Additional Resources
Tips and Tools
Example
Click to open
Description
Additional Resources
Tips and ToolsExample
Quality Infrastructur
e
Additional Resources for Developing QM Infrastructure
• National Quality Center (NQC) Quality Academy: QM infrastructure—how to
establish a quality management committee
• NQC Quality Academy
: Integrating quality into all aspects of an organization
• NQC Quality Academy: Systems thinking
• Health Resources and Services Administration:
Redesigning a system of care to promote QI
Performance Measures &
Annual Goals
Description
Additional Resources
Tips and Tools
Example
Performance measures is the system used to track desired client
outcomes and the program’s progress towards achieving those outcomes.
These outcomes should be as good as or better than national treatment
standards.
Annual goals are drawn from the list of performance measures. Key
stakeholders decide which performance measures to focus upon improving
for the year.
Performance Measures &
Annual Goals
Description
Additional Resources
Tips and Tools
Example
Performance Measures:
• Identify critical aspects of care and services provided, and
• Develop indicators, and measure how well the program is progressing
towards achieving desired outcomes in care and service
• Choose measures from reputable sources (such as HRSA, CDC, HCS, etc.)
• Obtain data from multiple sources to ensure accurate reporting
Annual goals:
• Key stakeholders should be responsible for choosing a few goals each year
(no more than 5)
• Benchmarks should be set for each chosen performance measure
• Improvement activities for the year should be designed to improve chosen
performance measures
Performance Measures &
Annual Goals
Description
Additional Resources
Tips and ToolsExample
Click to open
Description
Additional Resources
Tips and ToolsExample
Additional Resources for Creating Measures and Annual Goals
• National Quality Center (NQC) Quality Academy:
How to develop ADAP quality indicators
• NQC Resources: Measuring performance in HIV care—how to collect
performance data and examples of HIV quality indicators
• NQC Resources: Measuring clinical performance—a guide for HIV health
care providers
• NQC Resources: Data collection tools
• Institute for Healthcare Improvement:
Science of improvement—establishing measures
• Health Resources and Services Administration (HRSA):
Performance management and measurement
• HRSA: Management data for performance improvement
Performance Measures &
Annual Goals
Processes & Projects
Description
Additional Resources
Tips and ToolsExample
Your QM Plan should explain the processes you use for selecting,
documenting and measuring improvement projects.
Quality improvement (QI) processes refer to the criteria for selecting
improvement projects, documenting projects/status/results, tools and
techniques used for improvement activities (i.e., Lean, PDSA, Model of
Improvement, etc.), feedback and evaluation of projects.
QI projects are systematic and documented activities designed to improve
programmatic processes and/or outcomes of processes.
Processes & Projects
QI processes
• Describe the process for how you choose and prioritize projects
• Describe how you monitor and document your projects
• Describe how you ensure your projects can be linked to specific
performance measures, annual goals, strategic goals or the mission
statement
• Describe what quality improvement tools you use for projects
QI activities
• List program activities and how they were selected
• Describe your improvement projects, and what project teams and quality
improvement tools you will use
Description
Additional Resources
Tips and Tools
Example
Processes & Projects
Description
Additional Resources
Tips and ToolsExample
Click to open
Additional Resources for QM Processes and Projects
• National Quality Center (NQC) Quality Resources:
Conducting quality improvement activities—essentials to implementing
quality improvement projects
• NQC Quality Resources: The improvement guide
• The LeanOhio information kit
• The Institute for Healthcare Improvement: Model of improvement
Description
Additional Resources
Tips and ToolsExample
Processes & Projects
Yearly Program Activities
Description
Additional Resources
Tips and Tools
Example
Yearly program activities are improvement projects designed to improve the
program (and ultimately improve upon client outcomes). Activities and
measures are chosen based on pre-determined criteria. Improvement projects
must be measurable and align with the agency mission.
Yearly Program Activities
• List your criteria for choosing projects, such as financial benefits,
efficiency, etc. and who will be involved in prioritizing projects
• Create SMART objectives: specific, measurable, attainable, relevant, and
timely
• Document your process for tracking projects
• Explain the processes you will use and how your objectives will be linked to
specific performance measures
• Include the who, when, and how about each activity
• Determine how you will be reporting your measures to key stakeholders
Description
Additional Resources
Tips and Tools
Example
Yearly Program Activities
Description
Additional Resources
Tips and Tools
Example
Click to open
Additional Resources
• Health Resources and Services Administration :
Readiness assessment & developing project aims
• National Quality Center: QM program assessment tools
Description
Additional Resources
Tips and Tools
Example
Yearly Program Activities
Stakeholder Participation
Description
Additional Resources
Tips and ToolsExample
Stakeholders refer to anyone who has a concern or interest in something,
and who may be affected in some way by your RW QM program actions,
objectives, or policies. Address how different stakeholders are involved in
your QM program:
• How are internal and external stakeholders involved in/impacted by your
program? (impacts may be negative or positive.)
• How are your quality improvement activities communicated to them?
• What opportunities are you providing for them to learn about quality?
Stakeholder Participation
• Create a chart that lists internal and external stakeholders and their
functions/responsibilities
• Include:
• Providers
• Consumers
• Sub-grantees
• Other Ryan White CARE Act Parts
• Resources impacted by QM program (e.g. databases managed by IT,
transportation managed by DAS, etc.)
• List proposed training opportunities for stakeholders
Description
Additional Resources
Tips and Tools
Example
Stakeholder Participation
Description
Additional Resources
Tips and ToolsExample
Click to open
Additional Resources for Engaging Stakeholders
• National Quality Center Quality Academy:
Engaging staff and consumers in QI work
• Project Management Institute: Engaging stakeholders for project success
• Health Resources and Services Administration: Improvement teams
Description
Additional Resources
Tips and ToolsExample
Stakeholder Participation
Communicating Reports & Initiatives
Description
Additional Resources
Tips and ToolsExample
Integrating QI into an organization and culture requires communication with
all stakeholders (internal and external) about successes and updates.
Storyboards are a great tool for sharing this information. Your successes
become their successes and increases both QI visibility and perceived value
within the organization.
Communicating Reports & Initiatives
Compile a list of your stakeholders, important information, and important
dates, then create a chart with the following columns:
• What you will be communicating (e.g. templates, data, reports, etc.)
• Who will be communicating it (supervisor, chairperson, QI team lead, etc.)
• How you will communicate it (e.g. electronic, mail, teleconference, etc.)
• To whom you will communicate the information (agency, committee, etc.)
• When (or how often) you will communicate it
Description
Additional Resources
Tips and Tools
Example
Communicating Reports & Initiatives
Description
Additional Resources
Tips and ToolsExample
Click to open
Additional Resources
• Healthcare Information & Management Systems Society/Robert Wood
Johnson Foundation:
Lessons learned in public reporting: deciding what to report
• Quality Assurance & Performance Improvement: Storyboard guide for PIPs
(performance improvement project)
Description
Additional Resources
Tips and ToolsExample
Communicating Reports & Initiatives
Evaluation
Description
Additional Resources
Tips and ToolsExample
The evaluation explains how your QM program will assess it’s own
performance in terms of:
• Infrastructure: how effective is your existing infrastructure? Can it be
improved?
• quality improvement activities: were goals met? If so, how effective were
your activities?
• Outcome performance measures: were your measures appropriate for
assessing clinical and non-clinical HIV care? Were goals met? Were
stakeholders informed? Was training provided?
• Improvement: how can your QM program improve upon the prior year’s
results?
Evaluation
• Explain who is performing your QM program’s evaluation and when
• Compare your annual quality goals with your year-end results
• Use your findings to plan next year’s activities; learn and respond from
your past performance
• Routinely use organizational assessment tools like those provided by the
National Quality Center
Description
Additional Resources
Tips and Tools
Example
Evaluation
Description
Additional Resources
Tips and ToolsExample
Click to open
Additional Resources for evaluating your QM program
• National Quality Center Quality Academy: QM program assessment tools
• Centers for Disease Control: A framework for program evaluation
Description
Additional Resources
Tips and ToolsExample
Evaluation
Software
Microsoft PowerPoint
2013
Software
Instructional DesignerSponsor
Credits & Contact
Contact information
Instructional Designer
Jamie L. Perez, M.S.,
M.Ed.Sponsor
Ohio Department of HealthHIV Care Services Section246 North High Street, Columbus, OH 43215http://www.odh.ohio.gov/hcs
Contact [email protected]
Date availableMay 2015