How do I incorporate QI into the day-to-day activities of the program? TOP

There is no one way to incorporate quality improvement activities into your day-to-day operations. The nine (9) steps outlined in Section 3, provide a guide on how to implement a QM program. It is important to have a quality plan in place, with priorities determined by the Leadership of the organization. These priorities should be communicated to all program staff. Quality Improvement activity updates should be provided at all program staff meetings. QI data collection, tracking systems and improvement strategies can be folded into daily workflow. Each staff member can be included on some level to promote shared accountability and buy-in on all levels.

Train everyone in CQI tools and techniques so that they understand its focus on improving systems of care and not on individual performance. This will help to reduce fear that may be present. Avoid punitive use of data collected for QM for this same reason.

Encourage dialogue and suggestions around improving care delivery from every level of staff.

We are a small agency funded to provide case management services only. Where do we get started? The steps to implementing a quality management program seem very overwhelming for a small agency. How much do we really have to do?  TOP

The nine steps to implementing a quality management program can seem overwhelming especially for small agencies with limited staff and administrative personnel. These steps are intended to be guiding principals that if fully implemented will lead to a strong sustainable QM program. However, the most important step for you to take is to “get started”. Start with the self assessment in the beginning of this manual. Maybe you already have data available, but you’ve never really analyzed it in a formal manner. Maybe you have a team of case managers who work beautifully together and are always finding ways to improve services. Maybe this group can serve as your first quality project team. Start with what you already have in place; recognize your strengths and build from there. HRSA will look for you to formalize your processes, and show that you are identifying opportunities for improvement and making incremental but effective changes.

How do I avoid duplicate data collection for quality improvement activities for multiple funding sources and multiple regulatory entities?  TOP

CAWe all wish we had one big database that provided us with all the data we needed, in any form we needed it, at the touch of a button. Unfortunately funders and regulatory agencies are very specific in how they would like demographic and service data reported and there is no magic bullet to accomplish this. When it comes to quality improvement data collection, most agencies will encourage you to collect meaningful data to measure your quality of care based on the priorities that you have set for your program based on your mission. For instance, if you are a medical program you will surely want to show evidence that you are providing care based on recognized national standards of care. If you are an AIDS Service Organization (ASO) you will collect data that reveals your ability to provide case management services or other supportive services to your clients. This kind of data and documented activities to improve services will generally satisfy an agency that you are regularly monitoring and evaluating the care and services that you deliver.

For example, a JCAHO accredited and Medicaid-approved provider should consider using a single HIV/AIDS improvement project, where feasible, to meet the quality management requirements of the Ryan White CARE Act, Medicaid, and JCAHO. The requirements would need to be consolidated and the higher standards applied to each domain of the project, but in this way, duplicate efforts could be avoided. RE

How do I keep busy physicians engaged in the process? TOP

Clinical providers have many competing priorities in today’s health care system, including patient care, research, meetings, etc. Quality Management activities are not always on the top of the list, though clearly they care about the quality of care they provide to their patients. HIV providers are a unique and committed group.

One strategy is to make sure that the physicians are part of the process of choosing the performance measurements. If they care about the topic you will more likely keep them engaged. Another strategy is to highlight some projects that have improved care so that they can see how the process can work. Build QM discussions into existing meetings and forums so that additional meetings do not need to be scheduled. Finally, engage a physician leader in the process and utilize their expertise and enthusiasm to get others involved.

How do we deal with difficult personality styles that are not always conducive to good teamwork?  TOP

Some people are born team players and seem to understand innately how to work with a group of people to achieve a common goal. Some people aren’t. Individuals used to being in charge and making unilateral decisions, may have a difficult time adapting to a system that promotes a team approach to decisions. Physicians, in particular are trained to be the “captain of the ship”. In an operating room this is a useful and critical trait. In a team setting where decisions are shared, processes examined in great detail and changes tested before being fully implemented, some individuals may become frustrated adapting to the process. Organizations with a very entrenched hierarchical structure may also find individuals slow to adjust to a philosophy of teamwork. However, remember that human beings are highly adaptable. Teamwork is a skill that can be taught and nurtured. Remain optimistic and give each team member ample time to adjust. Sometimes team pressure alone will help to neutralize difficult personalities. When an individual continues to exhibit behavior that is counterproductive to the process, senior leadership may need to step in, and in some cases, the individual may be asked to leave the team. The important thing to remember is that no one individual should be allowed to retard the momentum of the team.

Does this QI process supersede my current organizational standards and compliance measures?  TOP

No. Some organizations are accredited and have other types of standard compliance measures in place. This process is meant to complement existing systems, where appropriate, not replace them. For example, regulatory organizations such as, JCAHO, State and local department of health all have external regulatory requirements that are incorporated into the organization’s plan to ensure that the organization meet strict regulations. If the accrediting and regulatory bodies' requirements match those of the RWCA, then there is no need for duplication.

A JCAHO accredited and Medicaid-approved grantee should consider using a single HIV/ AIDS improvement project to meet the quality management requirements of Ryan White, Medicaid, and JCAHO. The requirements would need to be consolidated and the higher level standards applied to each domain of the project will satisfy the requirements.

When in doubt, develop a crosswalk with the accrediting bodies’ regulatory requirements and those of the RWCA.

What indicators should we be examining? TOP

The first step in choosing an indicator is to determine concisely what you want to know. What is the performance standard that you want to measure? For Ryan White funded agencies, an easy way to prioritize is to review your project work plan. What did you say you were going to accomplish? How do you know that you were successful? Do you have data that supports every key goal and objective? If you are heavily funded to provide clinical care, you should prioritize adherence to PHS guidelines to show that you are providing care that meets national standards. If you are funded to provide case management services, what are the standards of service that you expect from your case management team?

Starting with recognized standards of care or service is always a good first step.

Is there a minimum number of indicators that we should monitor?  TOP

No. This depends on the variety of services you provide and the size of your organization. As above, try to include one key indicator for each goal and objective in your work plan. You can start small and increase the number of indicators over time. The most important point is to get started.

Is it enough to just focus on clinical care and not look at support services, such as case management?  TOP

Probably not. We know that supportive services can enhance an individual’s ability to adhere to his/her clinical care. If you provide both clinical care and supportive services you will need to assess the quality of both. If you provide only clinical services and refer your patients to other organizations for case management services you may want to assess the referral process and access issues. This would be a great opportunity to work collaboratively with another agency and promote continuity of care.

Who should be part of the QM teams?  TOP

Everybody. At some point everyone in your organization should be engaged in a project team. You want to avoid having the same people on the teams, except in small programs where staffing may be an issue. Larger programs should consider every staff person when assigning team members.

How does HIPAA impact QM?  TOP

The new HIPAA (Health Insurance Portability and Accountability Act) regulations are intended to standardize the way health care data is exchanged electronically in order to streamline the processing of health care transactions, reduce the volume of paperwork, save money, and provide better service for providers, insurers and patients. Consult with your organization to determine how HIPAA impacts on your program and what procedures they have put into place to assure compliance. (See attached HIPAA resources for additional information on the HIPAA).