Tools for Grantees: Quality Management Manual

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 VII. Appendices

Appendix B

QM Plan Grid

HIV Program Peformance Improvement Plan
Activities Table for 2003
Major Function Important Aspect of Care Opportunity Identified Approach Staff Sponsor/ Leader Dates/ Timeline
Clinical Care PPD Screening: PPD placed and read on an annual basis Yes
PPD’s placed routinely but not read consistently.

Baseline and follow-up data collected utilizing HIVQUAL.

Assess standard of care for low prevalence area.

empty cell for entering data Annual Fall Campaign (Sept through Dec.)
empty cell Gynecological care Yes
Follow-up data collection with HIVQUAL revealed a decrease in adherence to annual pelvic exam standard.

Develop and implement improved GYN care tracking form; Further evaluate care to determine adherence to GYN standard; implement improved follow-up.

Continue to track progress.

empty cell for entering data Data collected quarterly
empty cell Hepatitis Screening Yes
Initial data collection revealed 70% of charts had documented Hepatitis A, B, C labs and vaccine.

Develop Hepatitis stamp for medical record.

Educate providers.

empty cell for entering data Data collected quarterly
empty cell Dental Care Yes
Initial data revealed fewer than 50% have documentation of last dental visit.

Add annual dental exam. Add section on progress note to track annual dental visit.

Collaborate with dental school to increase access to dental school appointments.

empty cell for entering data Data collected quarterly
Mental Health Services Kept Psychiatry visits Yes
High rate of no show noted for new patients scheduled for mental health visits.

Monitor new patients in care by reviewing initial patient questionnaire regarding alcohol use and psychiatric symptoms.

Assess rate of referral for new patients and kept appointments.

Plan to improve use of mental health services and to reduce no shows.

empty cell for entering data

Missed appointment rates reviewed quarterly

Monthly Case Conferences for difficult patients

Patient Education Assessment of educational needs Yes
Need to assess patients educational needs and prioritize.

Utilize Peer Advisory Board to provide input regarding all patient education events and materials.

Assure basic HIV education incorporated into each medical visit.

empty cell for entering data Ongoing
Continuity of Care Patient retention Yes
Retention rate assessed at 85% of patients seen quarterly.

Multiple approach:
Regularly assess patients not seen in 6 months.

Peer advocate to call all patients after missed appointment.

Monitor missed appointment rates.

 empty cell for entering data Ongoing