Overview of Quality Improvement at HAB  TOP

The Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) is committed to improving the quality of care and services and ultimately the quality of life for people living with HIV and AIDS. This commitment is made evident by the variety and depth of the efforts that HAB undertakes to address the quality of care, treatment, and training across all programs administered by the Ryan White CARE Act. This commitment has been further deepened by the 2000 Reauthorization of the CARE Act, which directs the programs under the CARE Act to develop and implement quality management programs.

Quality Management

All CARE Act programs are required to establish quality management programs to:

1. assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) guidelines for the treatment of HIV disease and related opportunistic infections; and

2. develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services.

HRSA/HAB’s working definition of quality is “the degree to which a health or social service meets or exceeds established professional standards and user expectations.” In order to continuously improve systems of care, evaluations of the quality of care should consider the service delivery process, quality of personnel and resources available, and the outcomes. The overall purpose of a quality management program is to ensure that:

• Services adhere to PHS guidelines and established clinical practice;
• Program improvement includes supportive services linked to access and adherence to medical care; and
• Demographic, clinical and utilization data are used to evaluate and address characteristics of the local epidemic.

A quality management program is a systematic process with identified leadership, accountability, and dedicated resources and uses data and measurable outcomes to determine progress toward relevant, evidence-based benchmarks. Quality management programs should also focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement and be adaptive to change. The process is continuous and should fit within the framework of other programmatic quality assurance and quality improvement activities, such as JCAHO and Medicaid. Data collected as part of this process should be fed back into the quality management process to assure that goals are accomplished and improved outcomes are realized.

Purpose of the Guide  TOP

HRSA is committed to improving the quality of health care services for the Nation’s underserved and vulnerable populations. HRSA’s goals are carried out through four strategies outlined in the agency’s Strategic Plan of 2000-2005.

1. Eliminate barriers to care;
2. Eliminate health disparities;
   
3. Assure quality of care; and
4. Improve public health and health care systems.

The third strategy “Assure Quality of Care” states, “HRSA will assure quality of care is provided to the underserved by fostering a diverse, quality workforce and the utilization of emerging technologies. Sub strategies include: a) Promote appropriateness of care, b) Assure effectiveness of care and c) Improve customer/patient satisfaction.”

HRSA’s HIV/AIDS Bureau is committed to supporting HRSA’s strategic plan by developing and implementing technical support to grantees providing care and services to HIV-infected and affected individuals. The intent of the new legislation around quality improvement is not to apply a “one size fits all” model across all grantees. The approach in improving and demonstrating quality of care in Ryan White CARE Act grantees may be as unique as the individual grantees. However, in order to demonstrate quality of care in an objective and tangible manner, certain components must be in place. This manual offers a framework to demonstrate quality care and provide specific information and tools that will help grantees to plan, design, measure, assess, and improve performance.

Through quality management programs, grantees will be able to provide information to HAB to demonstrate the overall effectiveness of their programs.

Ryan White Care Act themes that can be addressed and supported by quality management programs are:

• Improved access to and retention in care for HIV-positive individuals aware of their status;
• Quality of services and related outcomes; and
• Linkage of social support services to medical services.

Background and Rationale TOP

Legislative Requirements/Reauthorization

All CARE Act grantees are required to establish quality management programs to:

• Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections; and
• Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services.

The overall purpose of a quality management program is to ensure that:

• Services adhere to PHS guidelines and established clinical practice;
• Program improvement includes supportive services linked to access and adherence to medical care; and
• Demographic, clinical, and utilization data are used to evaluate and address characteristics of the local epidemic.

A quality management program should have the following characteristics:

• A systematic process with identified leadership, accountability, and dedicated resources;
• Use of data and measurable outcomes to determine progress toward relevant, evidence-based benchmarks;
• Focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement;
• Continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement (QI) activities (i.e. JCAHO, Medicaid, and other HRSA programs); and
• Data collected is used to feedback into the process to assure that goals are accomplished and they are concurrent with improved outcomes.

Quality management (QM) programs are often implemented to meet external regulatory and funding requirements. Regardless, organizations that embrace QM concepts and methodologies, and integrate them into the very structure of the organization and day-to-day operations, discover a very powerful management tool. Program evaluation becomes an ongoing dynamic process. Priorities are set and resources allocated based on objective information. Job satisfaction is achieved by the inclusion of personnel in decision-making processes and pride in the ongoing evidence of quality services. Team building can improve interpersonal relationships which are so critical to successful programs. Through the tools and techniques of quality management, you will be able to substantiate that you are providing quality care to every patient/client, every day.

Using this Guide  TOP

Although CARE Act grantees vary by type of organization, size, focus, and population served, all programs need to develop an ongoing method to measure, evaluate, and improve performance. Tools and techniques utilized to assess quality can be applied in any type of program, whether it is a small single site program or a large multi-site network. A successful quality management program is incorporated into a program’s existing structure and should reflect program-wide goals and objectives.

Incorporating quality improvement principles, tools, and techniques into the day-to-day culture and operations of the organization provides an effective method to evaluate your program’s performance, promote a coordinated approach to problem solving and help determine if established goals and objectives are being met.

This guide is intended to provide the tools to develop and implement a quality management program and support an ongoing partnership with HRSA to sponsor improved quality of care in all Ryan White CARE Act settings. It provides a step-by-step process that can be applied in any setting including large complex organizations with wide-ranging services as well as small single service providers. Though the nine (9) step process outlined in this manual may seem complex, it is designed for both the experienced and non-experienced grantee; as a starting point for some and as a reference for others who have had difficulty sustaining quality activities over time.

Use the guide to learn about:

• Common quality improvement terminology that is often used interchangeably.
• Use of guidelines and standards of care, whether they are clinical or service oriented, as your guide and starting point.
• Developing a framework to sustain quality improvement activities over time, including leadership support, planning, and priority setting.Where you need to start and how to incorporate QM into your existing organizational structure.
• Making decisions based on data, rather than hunches, to look for root causes of problems rather than react to superficial symptoms, and to seek permanent solutions rather than rely on quick fixes.
• The use of simple tools and techniques to measure, analyze, and improve care.
• Multidisciplinary project teams to promote change.
• Dedicating resources and time to quality improvement activities while sharing accountability and responsibility across the program/organization.
• Methods to track your progress and to communicate your successes.
• The use of internal and external data to measure care.
• Developing indicators to measure clinical care and supportive services.
• Incorporating customers into the quality improvement process.
• Designing quality improvement programs which meet regulatory requirements external to the Ryan White CARE Act, and avoid redundancy of effort.

Defining Terms  TOP

Quality improvement terminology is often used interchangeably, so it is important to begin with some working definitions.

Quality is the degree to which a health or social service meets or exceeds established professional standards and user expectations. Evaluation of the quality of care should consider 1) the quality of the inputs, 2) the quality of the service delivery process and 3) the quality of outcomes, in order to continuously improve systems of care for individuals and populations.

Quality Improvement (QI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of the processes of providing services to meet the needs of the individual and others. This term generally refers to the overriding concepts of continuous quality improvement and total quality management.

Continuous Quality Improvement (CQI) is generally used to describe the ongoing monitoring, evaluation, and improvement processes. It is a patient/client-driven philosophy and process that focuses on preventing problems and maximizing quality of care. The key components of CQI are:

Patients/clients and other customers are first priority.
Quality is achieved through people working in teams.
All work is part of a process, and processes are integrated into systems.
Decisions are based upon objective, measured data.
Quality requires continuous improvement.

Total Quality Management (TQM) is a somewhat larger concept, encompassing continuous quality improvement activities and the management of systems that foster such activities: communication, education, and commitment of resources.

Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards.

Performance is the way in which an individual, a group, or an organization carries out or accomplishes its important functions and processes.

A Performance Measure is a quantitative tool that provides an indication of an organization’s performance in relation to a specified process or outcome.

An Indicator is a measure used to determine, over time, an organization’s performance of a particular element of care. The indicator may measure a particular function, process or outcome. An indicator can measure:[1]

Outcomes are benefits or other results (positive or negative) for clients that may occur during or after their participation in a program. Outcomes can be client-level or system-level.

A Process is a sequence of tasks to get to an outcome. It is a goal directed interrelated series of actions, events, mechanisms, or steps.

A System is a group of related processes.

Team refers to a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable. Project teams are just one element of a quality effort, though an extremely important one. Teams should include a team leader or project sponsor to lead the initiative.

Continuum of Care relates to a system of connected services designed to match an individual’s needs with the appropriate level and type of medical, psychological, health or social service within an organization or across multiple organizations. Assuring quality of care across the continuum can be especially challenging.

Root Cause Analysis describes the process of developing permanent solutions to problems by first identifying all of the contributing and underlying causes of a problem.

Chronic Care Model is a tool to improve the care of individuals with chronic illness, including HIV/AIDS, which focuses on six essential elements: Self Management and Adherence, Decision Support, Clinical Information System, Delivery System Design, Organization of Health Care, and community. The model was originally developed by Ed Wagner, MD, MPH. (See the HAB Website to download additional information regarding the model.)

PDSA or Plan-Do-Study-Act is a widely used framework for testing change on a small scale.

Notes

[1] Joint Commission on Accreditation of Healthcare Organizations “Using Quality Improvement Tools in a Healthcare Setting," 1992, Oakbrook, Illinois. [ Return to Text ]