I. Executive Summary  TOP

This report outlines proceedings of the July 29, 2003 Technical Assistance Conference Call “Quality Management in HIV/AIDS Systems of Care.” The call is one in an ongoing series, organized by the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). Their purpose is to provide grantees and CARE Act providers with guidance on administering HIV/AIDS programs.

Call presenters included HRSA/HAB speakers (to outline policy and program expectations) and grantees (experiences in the field), as follows:

HRSA/HAB

• Magda Barini-Garcia, M.D., M.P.H., Acting Deputy Director, Division of Training and Technical Assistance, HRSA, HAB
• Laura Cheever, M.D., M.P.H., Acting Deputy Associate Administrator, HRSA, HAB

Grantees

• Pat Bass, R.N., M.A., Former Co-Director and Current Consultant to the AIDS Activities Coordinating Office of the Philadelphia Title I EMA
• Mark Loveless, M.D., Independent Consultant and Clinical Associate Professor of Public Health and Preventive Medicine at Oregon Health Science University
• Virginia (Ginger) Butler, Continuous Quality Improvement Coordinator for the Monroe County Health Department in Key West, Florida.

In addition to these presentations, two question-and-answer sessions allowed listeners to provide input and receive additional information and clarification on the presentations.

II. Quality and the CARE Act  TOP

Laura Cheever, M.D., M.P.H., Acting Deputy Associate Administrator
HRSA, HIV/AIDS Bureau

• Congress made a significant change in the CARE Act Amendments of 2000 by requiring quality management for all CARE Act grantees to insure that standards of care are met. Grantees must develop strategies to insure that quality care is delivered, with attention to support services that increase access to care and adherence to HIV medication regimens.
• With these mandates come new challenges. First is how to pay for these activities without impacting service provision. The legislation set-aside for quality management funds is one option. A second challenge is the learning curve of staff. HRSA/HAB’s quality management manual outlines some practical ways of educating staff on quality management programs. Third is the perception that quality management is an added burden. It is time consuming, but it is also part of the work grantees already perform in monitoring the care provided through their programs.
• At HRSA, quality management is part of an overall mission to enhance access to quality healthcare. The Government Performance Results Act of 1996 (GPRA) holds all Federal agencies accountable for program outcomes. HAB has long worked with grantees on quality initiatives, such as the Title III and IV primary care assessment tools and the New York State AIDS Institute’s HIVQUAL program.
• Grantee insights have guided HAB’s quality management efforts. HAB commends grantees for their efforts and feels that when quality management becomes intrinsic to a program, it becomes a powerful tool for managing patient care, maximizing resources, and improving employee morale by including them in decision-making and team building.
• What gets measured gets counted, what gets counted gets funded and what gets funded should be of high quality.

III. About Quality  TOP

Magda Barini-Garcia, M.D., M.P.H., Acting Deputy Director
Division of Training and Technical Assistance

• HRSA/HAB’s approach to quality is continuous quality improvement (CQI). CQI seeks to improve care, is ongoing, and is built into programs to continuously improve service delivery.
• There are many ways to do CQI and HRSA/HAB recognizes that flexibility is important.
• The Quality Management Technical Assistance Manual includes a nine-step process for implementing quality management programs. The manual defines quality terms, outlines the framework needed to sustain quality programs (time, resources, leadership and planning), and discusses the use of data to identify problems and seek solutions.
• Steps 1 and 2 are about getting started, includes things like teaching staff about quality, regular updates for staff, writing down tasks of quality team members and writing a quality plan. Steps 3, 4, 5 are about determining performance measures. This includes collecting and looking at data to assess your efforts and creating a team to identify improvements. Steps 6, 7, and 8 are about trying new approaches and comparing results. Step 9 is enjoying success, but also about starting the process over and tackling a new problem.
• This process is not complicated, but it takes time and resources. For experienced agencies, the manual can be used as checklists to make sure things are in place. For agencies new to the process, the manual outlines steps for putting a program in place.
• One important CQI tool featured in the manual is called the Plan, Do, Study, Act (PDSA) cycle. “P” or “plan” involves identifying an area of need or an opportunity for improvement and determining the root causes of the problem. “D” or “do” requires coming up with strategies to prevent the problem or improve the way things are done. “S” or “study” involves collecting data to evaluate the effectiveness of the strategies tested. “A” or “act” is about making these strategies part of the ongoing work. If strategies don’t work, you go back to the “plan” stage, and try again.
• An example of PDSA is done with the problem of clients missing their appointments. In the plan stage, missed appointments are identified as a problem. The “do” stage is about figuring out a way to decrease missed appointments, such as reminder calls. The improvement could entail establishing a set time to call clients before their appointments. The approach could be tried with a subset of patients, a specific clinic, or on a specific day, so that results can be compared with clients that don’t receive calls. In the “study” stage, the data would be reviewed to determine if the approach had resulted in a higher number of kept appointments for patients that were called. If so, then reminder calls could become standard practice in the “act” stage. If there is no change, another small test could be conducted.
• An added advantage of this approach is that it uses minimal resources and time.
• HAB has many resources available to help support grantees in quality activities. These tools can be downloaded from http:www.hab.hrsa.gov/tools.htm. Go to the CATIE TA Library and, in the search field, type in “quality.” Various resources and tools are aimed at meeting diverse grantee needs and environments. CAREWare and the CARE Act Data Report are also available on the HAB Web site on the “tools” menu.
• On-site technical assistance can be requested through project officers.

IV. Questions and Answers TOP

Question: I would like to know about the role of the Planning Council in the process of quality management.

Patricia Bass: In Philadelphia, the Planning Council and consumers have been involved from day one. In our earlier processes, we had the consumer satisfaction team, but in fact, now there is a quality committee that is part of the Planning Council and there is a representative from the Health Department on that committee. Additionally, consumers serve on expert panels that help evaluate standards. So it is very important that the Planning Council and consumers be involved.

Caller Comment: In New York, we have a similar process for gaining support from Planning Councils and networks. We have created a quality management consumer group that provides input to quality management activities for both clinical and support services.

Question: I work on the CQI program at Bronx Lebanon Hospital. In terms of using the PDSA cycle for TB screening, even though [we give] incentives, like metro cards, some clients do not come for their readings. Also, we have the same problem with women coming in for pap smears. Do you have any suggestions?

Laura: One approach that has been successful is to have the patient come in two days before the doctor’s visit and combine TB screening with a laboratory draw. So the labs and TB screen results can be read at the appointment, and it makes the doctor’s visit more productive for the patient.

Magda: You can use PDSA cycles to break down the process of doing pap smears. This can be especially helpful if they are not being done in the medical clinic and women are being referred to another clinic for pap smears. So you can break down that process and then start looking at where in that process the patients are falling off or the pap smears are not being done.

Question: For those of us who are in the clinical field providing primary HIV care, does our participation in HIVQUAL give appropriate indication of quality assurance in our HIV programs?

Magda: Participation in any quality management program where you can document your efforts on an ongoing basis is the bottom line.

Question: Are HRSA’s GPRA goals available through the Web site or, if not, where can I have access to them?

Magda: Information on GPRA goals can be found at:

http://www.whitehouse.gov/omb/mgmt-gpra/ and
http://www.hrsa.gov/04perplnhome.htm.

V. Grantee Presenters  TOP

Patricia Bass, R.N., M.A.
Former Co-Director and Current Consultant to the AIDS Activities Coordinating Office Philadelphia Title I EMA

• The Philadelphia Title I EMA strives to provide a continuum of HIV services to meet the needs of consumers at every stage of their health. Addressing the quality of services started from the beginning because it was necessary to develop a continuum of care that included all of our Ryan White service categories. The question was how to move from just counting service utilization to looking at the quality of services offered.
• The 2000 Amendments made the grantee even more aware of the urgency to examine the quality. Many had already started this process prior to the reauthorized bill. In Philadelphia, our quality system allows us to identify problems by reviewing deficiencies uncovered during site monitoring, as well as consumer complaints. It is important to remember that monitoring of providers in a non-punitive manner is essential, as is offering technical assistance or training to providers to foster improvement.
• Our first step in creating a quality management system was to hear from the stakeholders. This inclusion helped them understand that quality was not a matter of taking money away from care. Rather, it was a way to insure that people living with HIV disease got as good as, or better care, as those with other diseases.
• A consumer satisfaction team was established and made site visits at the same time as the administrative monitoring team. This allowed the grantee to gather information from the client’s perspective. The consumer team asked about the care provided, staff interactions with clients, how clients were treated, and whether they provided information and had their questions answered. We did this monitoring using an assessment tool that was developed with the help of our partner, the Pennsylvania AIDS Education and Training Center (AETC).
• The Pennsylvania AETC helped identify best practice guidelines and performance measures, which were developed for select groups of services. The Pennsylvania AETC convened panels of experts and trained providers and staff. They helped develop monitoring tools for site visits and chart reviews, and facilitated, participated and collected data and did the analyses.
• Providers were able to integrate these standards into their system and to use information as a beginning point in self-monitoring. Some required technical assistance.
• The approach was not effortless. Planning, collecting and analyzing data cost money. There were human resource costs including the training and retraining of stakeholders, staff time at the administrative office, and provider staff time.
• Had changes not been made, however, the invisible costs of inadequate healthcare systems, consumer complaints, and inappropriate levels of care would have persisted.
• The Philadelphia Title I EMA is now at the next phase in the process. Today, many providers can selfmonitor and report data back to the grantee and use the information in their own planning. TA continues to be provided as needed by the Pennsylvania AETC. The grantee has now implemented the PDSA cycle that Dr. Barini-Garcia described and it is provider driven.
• The benefits of our quality system include stronger linkages between funded agencies, best practice guidelines using local experts with diverse strengths, and performance measures that allow for uniform monitoring and feedback to the providers that allows them to address changes while identifying their strengths.
• Lessons learned include that quality is an ongoing process and as the disease changes, best practice guidelines and benchmarks need to be reviewed and changed. Buy-in from all stakeholders is important.
• Use available resources, as we used the Pennsylvania AETC.
• The process requires planning and building on the strengths of the provider network, consumers, Planning Council and the grantee. The goal is to provide access to, and retention in, primary care for all consumers. To be successful, we must continue to look at the system and identify strengths and weaknesses. We must identify gaps while continuing to provide current care within the current trends.

Mark Loveless, MD
Independent Consultant and Clinical Associate Professor of Public Health and Preventive Medicine,
Oregon Health Science University
Former Medical Director/Epidemiologist, Oregon HIV/STD/TB

• Title II programs in each State must assure access to HIV care and antiviral medications for persons living with HIV. In response to CARE Act directives, State AIDS Programs are actively developing quality management programs that are varied in their scope and complexity. The focus of these quality management programs will be on health outcomes for the entire HIV health services network in the State.
• The HIV care system is just a subset of the larger healthcare system and is generally not well integrated, may be disjointed, can be inefficient and is often plagued by red tape for both providers and clients.
• To improve the situation, Oregon’s Title II quality management program was designed to better integrate critical segments of the publicly funded HIV care network. This requires that the entire HIV services system be clearly defined, including the relative impact of other systems of care, such as Medicaid managed care, Title I programs, and private providers.
• In Oregon, we constructed a model for how the Title II HIV program fit into the entire Statewide HIV care system, both public and private. When that was accomplished, the quality management program was developed through five key steps.
• Step 1 was to establish the authority to perform quality management. In Oregon this is done through a set of assurances established with the county health departments, which deliver HIV services in Oregon. This authority is reinforced by the structure of the payment to the counties for the documentation of the services they deliver.
• Step 2 involved the integration of quality management into the Title II planning process. The Oregon HIV Care Coalition, our Statewide planning group, considers quality data in its planning process.
• Step 3 was to establish a uniform data collection system. HRSA’s CAREWare is used by all HIV case managers and county health departments to collect client-level data. Data analysis is performed at the service delivery site and by the State HIV program’s data and analysis section.
• Step 4 involved the establishment and implementation of HIV care service standards in all Title II service sites. These took two years to develop and were the result of a combined effort by consultants, program staff, HIV case managers and consumers.
• Finally, quality management outcomes and measures were developed. These outcomes are quantifiable, prospective and based on the established care standards.
• The new system has many benefits and a previously fragmented service system is now functioning as an integrated network. Additionally, there is more uniformity in the types of HIV services delivered.
• The quality management program will be more sustainable when there is an active training of the county health department line staff to implement CQI methodologies like the PDSA cycle.
• Resources are a challenge and the State must commit resources for technical assistance and training in data management, HIV care systems analysis and the use of data to improve care systems at the county level. Better systems for sharing information on best practices and lessons learned must be established between the State and county health departments. A third challenge is that the current system is primarily focused on quality management for HIV case management and will need to expand to include ADAP and the outcome of access to HIV medications. Finally, the Title II program must better understand and document the impact of quality management in other agencies and partners in the HIV delivery system, such as Medicaid and Title I.
• But, the system is currently producing the data that will allow program staff, community planning groups and care providers at the local level to be actively involved in measuring the improvement of HIV care quality in Oregon.

Virginia Butler, CQI Coordinator
Monroe County Health Department
Key West, Florida

• People are central to effective quality management. Leadership must be designated to someone with responsibility for guiding the process and accountability for following up. Our clinic had a quality improvement program in the past, but we never saw results. My job has been to keep the process moving, to follow up so that good ideas and changes do not get lost in the midst of our busy and important clinical work.
• A quality team of staffers, and in some cases volunteers, must be established to generate ideas and see them through. In Monroe County, we had a core team of three staff people: a doctor; a nurse; and myself. First, we determined that each patient should have one comprehensive physical examination each year. Second, we determined that each client should be seen every three months. Those goals required a larger quality team, including clients, case managers, front desk clerks, nurses, doctors, outreach workers and the MIS data entry person who would collect the data and run the reports to let us know if we were accomplishing our goals.
• We were mindful of everyone’s busy schedules and took care to work efficiently. We meet for one hour every two weeks and our agenda is modeled on the PSDA approach. Many things have been tested and studied to reach our goals. One approach involved a birthday card from case managers reminding clients to take care of their health. It was a great idea, but there was no way to measure it. Another approach we tested involved making a client’s next appointment before they leave the clinic. This has been so successful in helping clients keep appointments that it is now a routine part of our procedures.
• CQI has created a culture of improvement and a value system for our program. The process has been integrated into our daily work. We have seen improved health outcomes. It did not happen right away, but when it did it was extremely gratifying. With very small changes we have seen great improvements in the number of physical examinations and the number of patients coming in every three months, and that has led to improved viral load and CD4 outcomes.
• We have systems in place to check on ourselves, automatic props as reminders and the annual physical exam. CQI also provides the satisfaction of working together as a team, supporting each other to achieve agreed upon goals that are priorities for everyone.

VI. Questions and Answers  TOP

Question: I am the Project Director for a rural Title III program. We have only 1.5 FTEs on staff and I was wondering if others have been successful with volunteers in their CQI programs. Also, how do you handle the privacy and confidentiality issues?

Virginia: We sign on volunteers just like employees, with the same confidentiality procedures. We are careful not to use patient names in our CQI meetings.

Patricia: In our trainings we talk about confidentiality and all of those issues. I think it is really important for people to understand this issue if they are going to be doing this work.

Question: Thank you. I am the Title IV Coordinator here in Seattle and I was wondering if you could address the best methods or practices for utilizing consumers on quality assurance committees, first in regard to training, and second, in terms of retention.

Virginia: Our consumers stay involved because they feel like they are being listened to and they see the results of their input. Consumers are just as much a part of the team as anybody else.

Patricia: It’s really important to treat consumers as valued team members. They must be trained and their input must be valued. The AETC has helped a lot with training and re-training and has proven to be a real asset.

Question: What would be considered important outcome measures for medical case management?

Mark: Viral load and CD4 counts. Other ways of testing medical outcomes have more to do with process at this point, such as assessing the percentage of patients who have had a certain prophylaxis implemented at a particular CD4 count. The real trick is gather medical information, which is a big challenge for Titles I and II, particularly in terms of getting data from private providers. This is an ongoing process that does benefit from PDSA cycles to solve some of these problems and establish which outcomes are best.

Question: These medical data that were mentioned in Mark’s last response and an earlier one have brought us face-to-face with a HIPAA-related dilemma. Our local grantee wants to have unduplicated client-level data from each provider. The unique identifier used does not meet the standard of the identified data. Our consensus has been that we simply cannot supply client-level data, except with random identifiers, which do not meet the needs of the grantee agency. What data does HRSA require from the grantees and do you have suggestions for resolving this dilemma.

Ivana Williams (HAB Office of Policy and Program Development): HRSA is not requesting client level data at this point from grantees, except for certain projects under the Special Projects of National Significance (SPNS) program, or through special grant programs. My suggestion is to meet with the grantee and determine the most appropriate data that can be provided. Second, I encourage you to work and check with other Title I EMAs to see how they are collecting this data. I would also encourage each grantee to have contracts with providers that guarantee client privacy. Information on HIPAA and specific privacy rules are on the Office for Civil Rights website, which you can access by clicking the HIPAA link on the HRSA Web site at http://hab.hrsa.gov/links.htm#Insurance.

Question: Do you use measures by client, by program, by agency, by priority, and do you use sampling as opposed to trying to get all data for all clients?

Coleman Terrell (from the Philadelphia Title I EMA): Yes, we have always used sampling methods to get the information for our CQI process, although we are now moving towards getting population data using CAREWare and we are going to have that for primary care sites this year for most population data.

Questions: We are a Title II program in Texas and also have five Title I EMAs. I heard Dr. Loveless speak about working with Title II stakeholders, providers and others to develop standards of care as part of the Title II package. Are those the same standards used by Title I for ambulatory care and case management, and if so, how did you go about integrating them?

Mark: We worked with the community and developed these standards for Title II. Currently our Title I EMA in the Portland area is not using the same standards, but we are hoping that we will get to a point where both Title II and Title I case management standards are congruous. It is an ongoing process of just working with the Title I planning process and the Title I grantees to try to synchronize the case management standards. (Information on the Oregon State Title II program’s standards of care for case management can be found at: http://www.dhs.state.or.us/publichealth/hiv/cmstdrds.cfm#standards

Magda: Thanks Mark. If you would like to share any standards or protocols you’ve developed, you can go to the CATIE TA Library tools menu and click on “add an item.”

Question: Are there any tools that we can use in doing our capacity building with consumers? Also, how did the program in Florida involve consumers?

Virginia: Interestingly enough, we just jumped right in and did it. We just learned together. At the beginning that was an effective way. Now we are finding ourselves in the process of realizing the importance of training. There is no better training on a PDSA than just jumping in and doing it.

Patricia: I can add a little something from Philadelphia. We were lucky enough in Philadelphia to have Project Teach, which has a course in which we talk about standards of care. The course empowers consumers, and the program has become a significant partner in terms of this training and re-training.

Comment: We have been trained in the patient self-management program, developed by Stanford University, and have now started some workshops for patients. We are all very excited about it, but I will not be able to report on the results for a while.

Question: We are in the process of doing quality management simplification by addressing all of the different models that are out there. My question is about how to create fidelity, or alliance, with different providers who are using other QM models.

Magda: I think the answer to that really is about getting the partners all at the table and trying to determine the direction that you are trying to take with regard to quality management. There are a lot of requirements out there through Medicaid, through HRSA, and through other Funders and agencies, so the real challenge is to get to the table with other partners and dialogue about the best way to proceed.