Chapter 5
Quality Management  TOP

Introduction

HIV-related morbidity and mortality dropped dramatically in the latter 1990s due to advances in HIV/AIDS treatment. However, reductions have been unevenly distributed across HIV-infected populations due to such factors as unequal access to care and variable quality of services (e.g., treatment regimens, client support, provider skills). Quality management programs are designed to bring these benefits to all clients by improving the quality of care of all CARE Act services.

Quality management programs should:

• Support the development of higher quality care to people living with HIV disease (PLWH)
  

• Identify priority needs and client populations
  

• Support effective program management
  

• Demonstrate program value quantitatively by linking outputs (amounts of services provided) to outcomes (results)
  

• Identify and justify critical program activities and resources required to meet needs, and
  

• Enable local HIV service delivery networks and providers to perform better and to function as a system.

Legislative Background  TOP

Section 2604(c) (1) of the CARE Act legislation requires that the chief elected official (CEO) of a Title I eligible metropolitan area (EMA):

"shall provide for the establishment of a quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service (PHS) guidelines for the treatment of HIV disease and related opportunistic infection and, as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services."

Section 2604(c)(2) also provides for funding of quality management activities. It states that, in addition to the 5 percent of funding allocated for administrative costs, the EMA may use for quality management activities not more than the lesser of "5 percent of amounts received under the grant; or $3,000,000.

HAB/DSS Expectations  TOP

The CARE Act places major emphasis on enhancing the quality of care for PLWH. The complexity of HIV care—and the Act’s commitment to equal access to quality care for all PLWH—requires systematic efforts to ensure that CARE Act services are delivered effectively.

Definition of Quality

Quality is defined by HAB/DSS as the degree to which a health or social service meets or exceeds established professional standards and user expectations. In order to continuously improve systems of care for individuals and populations, evaluation of the quality of care should consider:

• The quality of inputs
  

• The quality of the service delivery process, and
  

• The quality of outcomes.

Purposes of Quality Management

According to the Managers’ Statement in the CARE Act Amendments of 2000, quality management programs are expected to accomplish three related purposes:

1. Assist direct CARE Act-funded medical providers to ensure that services adhere to established HIV treatment guidelines to the extent possible
   

2. Ensure that strategies for improving medical care include health-related supportive services that enhance access to care and adherence to HIV medical regimens, and
   

3. Ensure that available demographic, clinical, and health care utilization information is used to monitor HIV-related illnesses and trends in the local epidemic.

A successful quality management program should:

• Be a systematic process with identified leadership, accountability, and dedicated resources available to the program
  

• Use data and measurable outcomes to determine progress toward evidenced-based benchmarks
  

• Focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement
  

• Be a continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities (i.e., Joint Commission on the Accreditation of Healthcare Organizations [JCAHO], Medicaid, and other HRSA programs), and
  

• Ensure that data collected are fed back into the quality improvement process to ensure that goals are accomplished and improved outcomes are realized.

Coordination of Quality Management with Program Support Spending

In deciding what activities to undertake, Title I grantees should coordinate their quality management efforts with any program evaluation and quality assurance activities currently funded under Program Support, as prioritized and allocated by the planning council. 

Quality management activities may include but are not limited to:

• Continuous quality improvement (CQI)
  

• Use of the HIV/AIDS Bureau’s Primary Care Assessment Tool (PCAT)
  

• HIV/Quality Assurance (HIVQual), and
  

• Centers for Disease Control and Prevention (CDC)-supported adult spectrum of disease and chart review.

Program Support funds are used for CARE Act expenditures that are not service-oriented or administrative in nature. In clinical quality programs, supported activities may include, but are not limited to:

• Chart review
  

• Peer-to-peer review
  

• Data collection to measure health outcomes or indicators, and
  

• Other types of activities related to the development or implementation of a clinical quality improvement program.

HAB/DSS Monitoring

DSS will monitor grantee compliance with quality management requirements through questions in application guidances, progress reports, and site visits. CEOs will be asked to sign assurances in their annual applications attesting that appropriate quality management programs are in place.

Quality Management Methods  TOP

A number of tested concepts can be used in Title I quality management program efforts. They include quality assurance, quality improvement, continuous quality improvement (CQI), and outcomes evaluation. Continuous quality improvement and quality assurance are particularly relevant because of their focus on managing program quality. Each is described below.

Continuous Quality Improvement (CQI)

CQI is an ongoing process that involves service providers in ongoing activities to continuously improve service delivery. Activities include monitoring and evaluating inputs, processes, outputs, and outcomes. In contrast to quality assurance, which focuses on identifying and solving problems, CQI seeks to prevent problems and to maximize the quality of care. Steps in the CQI process include the following:

1. Plan – Identify problems (including their components—not just the big picture) and then plan strategies/tests that might result in improvements.
   

2. Do – Use strategies/tests that are designed to address problems.
   

3. Study – Collect and analyze data to see if strategies have resulted in improvements.
   

4. Act – If the strategies are effective, make them an ongoing activity. If they are not effective, return to the Plan stage. Use collected data to identify new ways to address problems.

Quality Assurance (QA)

Quality Assurance involves identifying problems in service delivery, designing activities to overcome these problems, and following up to ensure that no new problems have developed and that corrective actions have been effective. The emphasis is on meeting minimum standards of care.

Criteria Used to Assess Quality

Standards or targets can be used to determine whether a program’s implementation and/or outcomes are successful. Listed below are examples of criteria that can be used to evaluate service delivery processes and/or outcomes:

• Benchmarks (also called Best Practices). Benchmarks provide performance data that are used for comparisons. A program may compare its performance with that of a recognized high-quality provider that offers similar services or with leading performance standards for the health (or social services) profession. Some organizations use their own data as a baseline benchmark against which to compare future performance.
  

• Clinical Practice Guidelines. Such guidelines provide statements by recognized authorities on the "most appropriate" treatments for specific diagnoses or conditions. Clinical practice guidelines are developed to promote effective patterns of practice and to reduce inappropriate and unnecessary care. For example, the New York State Department of Health AIDS Institute has developed clinical practice guidelines for performance areas such as HIV staging, the prevention and management of opportunistic infections, and antiretroviral therapy. A computer software program called HIVQUAL is used to monitor the quality of care in each of these areas.
  

• Critical Pathways. These "pathways" are statements of the specific steps and procedures that should be followed when diagnosing, treating, and managing specific medical problems. The intent is to ensure that only the indicated steps are taken and that these steps are taken in the correct sequence. Because resources vary from one health facility to another, critical pathways are usually developed locally.
  

• Standards of Care. Standards of care are principles and practices for the delivery of health and social services that are accepted by recognized authorities and used widely. Standards of care are based on specific research (when available) and the collective opinion of experts.

HRSA/HAB Quality of Care Activities  TOP

The following resources supported by HRSA provide models for use in developing quality management programs.

HIVQUAL. This software-based CQI program is an approach to improving quality of care for PLWH. It focuses on systems improvement, information management, and performance management. Project components include HIVQUAL quality monitoring software along with quality improvement consultation aimed at building knowledge, skills, and capacity around quality systems in provider organizations. HIVQUAL was developed by the New York State Department of Health AIDS Institute for the Ryan White Title III program. For further information, contact the HAB Division of Community Based Programs at 301-443-9051.

Primary Care Assessment Tool (PCAT). This site visit protocol developed for CARE Act programs funded under Title III is used to evaluate the clinical, fiscal, administrative, and support services of CARE Act grantees. A quality improvement component is included in the clinical section. PCAT can be downloaded from http://hab.hrsa.gov.

Special Projects of National Significance (SPNS). HAB’s SPNS grants support the development of innovative demonstration projects that respond to the challenge of HIV/AIDS service provision to underserved and vulnerable populations. Select SPNS projects address quality of care. Others SPNS projects focus on such related topics as improving integrated care systems and evaluation of care systems.

HAB’s Quality Initiative. This project includes a series of "rapid learning strategies"—training sessions for CARE Act grantees. They are designed to accelerate the pace of quality improvement activities. For further information, contact HAB Division of Training and Technical Assistance (HAB/DTTA), 301-443-6366, and the Institute for Healthcare Improvement, HIV/AIDS Breakthrough Series Collaborative, 135 Francis Street, Boston, MA 02215, 617-754-4821, http://www.ihi.org.

Center for HIV Quality Care. The Center conducts research on appropriate standards of HIV care, including ancillary services at all stages of illness, and the cost of HIV care that corresponds to these standards of care. The effort is to create a national picture of Medicaid managed care benefit packages and capitation rates. For further information, contact the infectious Diseases Society of America, 66 Canal Center Plaza, Suite 600, Alexandria, VA 22314, 703-299-0204, http://www.idsociety.org, info@idsociety.org

Resources  TOP

HRSA Center for Quality Care. The Center for Quality Care focuses on defining appropriate standards of care for clients of HRSA programs, determining the cost of that care, and conducting research on and comparing benefit packages and capitation rates in Medicaid managed care plans. The Center is also documenting community-based provider experience with managed care plans. The HRSA Center for Quality Care’s website (http://www.hrsa.gov/quality) includes background information defining the components of quality and measuring quality, along with a listing of resources and links on quality care.

Outcomes Evaluation and the Logic Model. HAB has developed several outcomes evaluation guides. These guides provide a framework for outcomes evaluation and in some cases sample outcome measures. These guides either use a Logic Model or describe such a model as one option for outcomes evaluation. The Logic Model format was developed by United Way of America (http://national.unitedway.org) and is being used by an increasing number of CARE Act grantees. The model provides a clear, step-by-step process for outcomes evaluation and helps clarify the difference between outputs and outcomes. It also differentiates initial, intermediate, and longer-term outcomes. The following guides are available through the HAB website (http://hab.hrsa.gov) or may be obtained from HAB:

• Outcomes Evaluation Technical Assistance Guide. Primary Medical Care Outcomes. HRSA/HAB, 2000
  

• Outcomes Evaluation Technical Assistance Guide: Case Management Outcomes, HRSA/HAB, 2001
  

• Outcomes Evaluation: Getting Started, HRSA/HAB, 2001, and
  

• HRSA Care Action: The Resource Gap. Measuring Success: Evaluation, Outcomes, and Quality of HIV Care.

HIV/AIDS Evaluation Monograph Series. HAB’s Office of Science and Epidemiology has developed a series of publications to assist CARE Act grantees in designing and implementing evaluation studies. These monograph series are available through the HAB website (http://hab.hrsa.gov) or the HRSA Information Center at 888-ASK-HRSA. They include:

• Choosing and Using an External Evaluator, Report #1
  

• Using Data to Assess HIV/AIDS Service Needs: A Guide for Ryan White CARE Act Planning Groups, Report #2
  

• Cost and Performance-Based Contracting: A Guide for Ryan White CARE Act Grantees, Report #3
  

• A Practical Guide to Evaluation and Evaluation Terms for Ryan White CARE Act Grantees, Report #4
  

• An Approach to Evaluating HAART Utilization & Outcomes in CARE Act-Funded Clinics, Report #5, and
  

• Delivering HIV Services to Vulnerable Populations: What Have We Learned? Report #6.

Agency for Health Research and Quality. AHRQ is the lead Department of Health and Human Services (HHS) agency supporting research to improve quality of care, reduce costs, and increase access to essential services. Website: http://www.ahrq.gov.

The National Quality Measures Clearinghouse (NQMC). Under development by ECRI through a contract from AHRQ, the National Quality Measures Clearinghouse is designed to provide an Internet-based resource of evidence-based health care quality measures. Using a standardized language and common platform, the NQMC links two well-established AHRQ resources:

• The National Guideline Clearinghouse (NGC), a public resource for evidence-based clinical practice guidelines sponsored by AHRQ in partnership with the American Medical Association and the American Association of Health Plans. An Internet-based repository of clinical practice guidelines, it allows for detailed comparisons across different guidelines.  Summaries of guidelines are provided for clinical, methodological, and bibliographic areas.
  Website: www.guideline.gov.
  

• CONQUEST, the Computerized Needs-Oriented Quality Measurement Evaluation System, a set of computerized databases of clinical performance measures developed by AHRQ. It provides information on tools to assess the quality of health care delivered by providers. CONQUEST is being enhanced and updated through the project. 
  Website: www.ahrq.gov/qual/conquest.htm.

The NQMC will allow users to search these databases in combination and receive a report that lists evidence-based quality measures and guidelines.

National Forum for Quality Measurement and Reporting. This private, nonprofit organization has responsibility for the creation of comprehensive quality measures that are consistent with national aims for quality improvement. Website: http://www.quality.forum.org. 

U.S. Consumer Gateway Health Care Quality Page. Provided are information and links to numerous aspects of health care quality, including selecting a plan, purchasing health care services, and privacy. Website: http://www.consumer.gov.

HRSA Center for Quality: Links. Listed here are organizations that deal with quality care as well as other public health issues. Website: http://hab.hrsa.gov/links.htm#qc.

Business and Higher Education Developed CQI and Total Quality Management (TQM) Information. Business-focused CQI information can often be applied to the health care setting and used to advance the quality of HIV/AIDS services. Many business-oriented websites require a fee or membership to access CQI and TQM information. See the following:

• American Society for Quality (ASQ). The ASQ website includes an introduction to Quality, an online catalog including a listing of education courses and conferences, an on-line directory for products and services for quality and continuous improvement, and a Quality search option. 
  Website: http://www.asq.org.
  

• Office of Continuous Improvement (OCI), University of Texas at Houston. The OCI website includes resources and information on quality improvement, re-engineering, and other change management initiatives at both private and public institutions. This site includes a Quality Improvement Tools Tutorial that outlines the most commonly used quality improvement tools and methodologies.
  Website: http://www.uth.tmc.edu/ut_general/admin_fin/cqi/index.htm.
  

• National Committee for Quality Assurance. The NCQA website includes resources, information, and training opportunities on evaluating health care. This site includes information on The Health Plan Employer Data and Information Set (HEDIS), a performance measurement tool that contains a set of standardized measures specifying how health plans collect, audit, and report on their performance in important areas of health and customer satisfaction. 
  Website: http://www.ncqa.org.

Quality Assurance Reporting Requirements, A Report on Managed Care Performance.

This report is the New York State Department of Health’s annual publication of quality, access, utilization, and descriptive data collected from managed care plans licensed to operate in New York State. The report is made available to managed care plans, providers, purchasers, and consumers as part of the Department’s overall strategy to improve the quality of care provided to New Yorkers by managed care plans and to increase accountability to the public. Website: http://www.health.state.ny.us/nysdoh/mancare/main.htm.

References  TOP

Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). "Quality of Care: HRSA/HAB Resources." Available on the HAB website: http://hab.hrsa.gov.

HRSA, HAB. "Quality Assurance and Improvement," CARE Act National Technical Assistance Call. Rockville, MD: U.S. Department of Health and Human Services, August 1995.

HRSA, HAB. "Use of Funds for Quality Management Programs," Title I Reauthorization Letter #4, 2001.