Sample Quality Management Plan

Organization Name ______________________________________________________

I. Purpose:

The purpose of this plan is to set forth a coordinated approach to addressing quality assessment and process improvement at ____________________________. The program has established as its mission (insert mission statement, i.e. excellence in HIV-related patient care, education and research).

II. Goals and Objectives:

A systematic, department-wide process for planning, designing, measuring, assessing and improving performance with the following components:

A. Develop a planning mechanism incorporating baseline data from external and internal sources (list data sources) and input from department leadership, staff and patients. Clinical, operational and programmatic aspects of patient care will be reviewed.

B. Emphasize design needs associated with new and existing services, patient care delivery, work flows and support systems which maximize results and satisfaction on the part of the patients and their families, physicians and staff.

C. Evolve and refine measurement systems for identifying trends in care and sentinel events by regularly collecting and recording data (through a valid sampling program when appropriate) and observations relating to the provision of patient care across the continuum.

D. Employ assessment procedures to determine efficacy and appropriateness and to judge how well services are delivered and whether opportunities for improvement exist.

E. Focus on improving quality in all of its dimensions by implementing multidisciplinary, data driven, project teams and encouraging participatory problem solving.

F. Promote communication, dialogue and informational exchange across the department and throughout the organizations reporting structure, with regard to findings, analyses, conclusions, recommendations, actions and evaluations pertaining to performance improvement.

G. Strive to establish collaborative relationships with diverse community agencies for the purpose of collectively promoting the general health and welfare of the community served.

III. Structure

A. Framework

The department’s leadership group, INSERT TITLES is accountable, responsible and answerable for planning, directing, coordinating and improving healthcare services in the HIV Program. This leadership group approves the performance improvement plan, and reviews quality improvement activities during its regular meetings. A Quality Committee (QC) has been established, under the direction of the (medial director, administrator, etc.) (see QC Goals and Objectives).

The programs Consumer Advisory Board was established to assist in the quality improvement activities and will participate in specific projects as appropriate.

The department’s quality activities are reported through the hospital’s Total Quality Council which oversees, prioritizes and directs planning, designing, measuring, assessing and improving organizational performance.

Through the Division of Medicine, the HIV program also provides ongoing Quality improvement reports to the Division Chiefs meeting (Infectious Diseases, Internal Medicine).

B. Content

The program is designed to address QA/PI content regarding the following major functional areas and important aspects of care:

• Clinical Primary Care
• Patient and Staff Education
• Continuity of Care
• Patient Satisfaction
• Case Management
• Medical Record/Information Systems
• Managed Care/Utilization Review

Special attention will be given to high volume, high risk and problem prone areas as well as areas with external regulatory requirements.

C. Data Collection Plan

Selection of performance measures for the major functional areas and the important aspects of care and service.

Regular review of data for performance measures from a variety of sources will occur as per the attached schedule. The Data Manager and the Quality Management Coordinator will coordinate these activities. Data reports will be presented for review to Quality Committee and designated teams. Data sources will include but will not be limited to:

• Clinical Measures utilizing HIVQUAL software program and based on established HIV care guidelines
• Patient Satisfaction Survey results administered through the Office of Public Relations
• Demographic data, visit frequency and missed appointment data from CAREware and unit based database
• Utilization pattern and pharmacy use prepared by Managed Care Organizations

Data collection will be implemented utilizing appropriate sampling methodology and will include both concurrent and retrospective review.

D. Assessment and Evaluation

Assessment and evaluation of the data will be performed by various existing teams who will determine if the data warrants further evaluation. Based on this ongoing review, priorities will be set and opportunities for improvement identified.

E. Multidisciplinary Team and Development of Improvement Plan

Once an opportunity for improvement has been identified a multidisciplinary team will be convened to analyze the process and develop improvement plans. These teams will include those staff members closely associated with the process under study. Every attempt will be made to include individuals from other departments who may be impacted by changes made by the team and to help promote collaboration between departments.

Continuous Quality Improvement Methodology will be utilized and will include but not be limited to the following:

• PDSA (Plan/Do/Study/Act)
• Flow Chart Analysis
• Cause-and-Effect Diagrams
• Brainstorming
• Observational Studies/patient flow
• Activity Logs

Quality Committee/Team Meeting Record Improvement Plans will be developed and implemented by the teams. Improvements may include:

• System Redesign
• Education (Staff/Patients)
• Clinical Guidelines review, revision or development
• Procedure and policy changes
• Form development or revision

All improvement plans will be communicated to all staff and to patients if deemed appropriate. Meetings, e-mail, memos, informal verbal communication are all considered appropriate methods to communicate the team’s activities and improvement plans.

F. Sustaining Improvements

Regular feedback regarding improvement projects is critical to its success in sustaining improvements over time. Once an improvement plan has been successful a regular monitoring schedule will be implemented to determine whether the plan remains successful over time. A calendar for ongoing monitoring is attached.

G. Communicate results to relevant individuals and groups

As described in Section III, Structure, all performance activities of the HIV Program will be reported to the appropriate inter- and intra-departments.

Signatures: (leadership group)

Executive Director __________________________________________ Date _________________

Medical Director __________________________________________ Date _________________