Overview  TOP

The goals, purpose and type of agencies funded across the Titles vary extensively.

Title I and II grantees serve as agents to distribute and administer funds while Title III and IV grantees function primarily as direct service providers.[4]

Expectations for implementing quality management at the administrative level have not been defined as clearly as the quality management expectations set for direct service providers. For Title I and II grantees, implementation of a quality management program has two main components:

1. Conceptualization and implementation of a quality management program across the defined service area, such as the EMA or State; and
2. Utilization of data for planning and monitoring implementation of the quality management plan.

Conceptualization and Implementation  TOP

An overall strategy for quality management must be conceptualized and developed for the service area. In some service areas, a standardized approach may be utilized where all providers address a common set of issues, such as tracking and monitoring referral outcomes for substance abuse services or provision of annual pap smears for women. In other service areas, each provider would be expected to implement set quality improvement activities, but the specific issues explored would be defined by the provider agency. Regardless of the strategy employed, the administrative agent is expected to work in conjunction with the planning body to develop a strategy that is most appropriate for the service area. Once the strategy or approach is defined, the specific quality improvement projects need to be prioritized and the requirements of sub-grantees to participate in the quality efforts delineated. The Request for Proposals can serve as a forum to clearly communicate the requirements related to quality management. Formal contracts can be used to reiterate the expectations related to participation in the region’s quality management efforts. Below are a few examples of quality outcomes that can be incorporated into the contracts with agencies that you monitor:

The contractor will:

• Conduct random chart audits of 10 percent of primary care population or 35 charts, whichever is larger.
• Identify and track two quality indicators during the grant year.
• It is recognized that some Title III and IV grantees serve as administrative agents for a network or consortium of providers.
• Participate in all evaluations, studies, and reviews conducted by either the administrative agent or the planning council/consortia regarding services funded with grant funds.
• Participate in the quality management program implemented by the administrative agent.
• Implement an ongoing quality improvement program to assure that medical care is provided in accordance with PHS guidelines.

As the grantee, planning bodies and individual provider agencies identify indicators and measures to track over time and across the region, a logical starting point is to look to the Standards of Care that have been developed and implemented.

The Standards are designed to guide service provision and set minimum expectations in the respective service categories. Indicators and performance measures can be based on these standards. Examples of measures include the following:

• Percent of clients enrolled that meet defined eligibility criteria;
• Number of referrals made for substance abuse services and appointments kept;
• Number of referrals made for mental health services and appointments kept;
• Percent of patients enrolled in case management whose service plan is current;
• Percent of primary care patients with visit(s) in the last 3 months;
• Percent of patients with CD4 count >350 cells/mm3;
• Percent of patients with viral load < 10,000 copies;
• Percent of patients on HAART;
• Percent of patients with PPD screens in the last 12 months;
• Percent of female patients with pap smear in the last 6 months;
• Percent of patients with Hepatitis B and C screening.

The specific measures and indicators selected should address questions or issues that are pertinent to the service area and can be used to improve service delivery. For example, if an EMA feels that clients are being lost to follow-up after an initial diagnosis of HIV infection, measures such as the following might be appropriate to track:

• Percent of patients entering primary care HIV-positive and asymptomatic; or
• Percent of newly diagnosed HIV-positive patients who have a follow-up appointment within 3 months of diagnosis.

As sub-grantees initiate and implement quality efforts, technical assistance can prove to be invaluable. A variety of strategies can be employed such as agencyspecific consultation, region-wide educational or discussion forums and provision of sample tools, such as patient satisfaction surveys or chart audit forms.

Utilization of Data and Monitoring Activities  TOP

As the grantee of record, Title I and II agencies are not only responsible for ensuring the services are provided in accordance with PHS guidelines and industry standards but are also responsible for globally assessing the system of care. The quality management program should enable the EMA or State to examine and refine their processes for administering the grant at the programmatic and fiscal level and ensure sufficient collaboration with the planning bodies to allow the region to remain responsive to changing trends in the epidemic.

Quality management data can play a critical role in informing the community and helping to identify needs and gaps in service; information that is necessary for planning bodies to make informed decisions. The information gathered through the quality management program can and should be used as part of the priority setting process to identify the key service categories for which funds should be allocated.

As contracts are executed and funds allocated, the grantee assumes responsibility for monitoring implementation of the quality management plan at both the level of the region and sub-grantee. Strategies to ensure compliance vary and can include site visits, submission of quarterly reports, submission of data for defined quality indicators and chart audits conducted by external reviewers. Over time, analysis and trending of data will guide the quality management plan, impact funding priorities, identify needs and gaps in service and challenge the region to enhance and improve the system of care. As improvements are made in one area, new measures can be selected to enhance another part of the service delivery system.

Characteristics of Quality Management Programs  TOP

As previously indicated, five key characteristics of quality management programs have been identified by HAB. The way in which these characteristics can be demonstrated will vary by Title and agency. Strategies for implementing QM programs and demonstrating the key characteristics are presented in Appendix I.

These strategies are provided as examples and are not required elements. The suggestions will, however, assist the grantee in meeting the legislative requirements related to quality management.

Notes

[4]It is recognized that some Title III and IV grantees serve as administrative agents for a network or consortium of providers. [ Return to Text ]