Ryan White HIV/AIDS Program Part A Manual

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VII. Program Guidance
  4. Clinical Quality Management
      Introduction
    A. Legislative Background
    B. HAB/DSS Expectations
    C. Quality Management Methods
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). Clinical Quality management programs are designed to bring these benefits to all clients by improving the quality of care of all Ryan White HIV/AIDS Program services.

Clinical quality management programs should:

  • Support the development of higher quality care to people living with HIV/AIDS (PLWHA)

  • 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.

CLINICAL QUUALITY MANAGEMENT:
CENTRAL TO ADDRESSING RYAN WHITE HIV/AIDS PROGRAM THEMES

  • Providing improved access to and retention in care for HIV-positive individuals aware of their status

  • Enhancing the quality of services and client outcomes

  • Linking social support services to medical services

  • Making program changes to respond to the evolving epidemic

  • Using epidemiologic, quality, and outcomes data for planning and priority setting, and

  • Ensuring accountability.

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A. Legislative Background

Section 2604(h)(5) of the Ryan White HIV/AIDS Program legislation requires that the chief elected official (CEO) of a Part A eligible metropolitan area/transitional grant area (EMA/TGA):

"shall provide for the establishment of a clinical 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/AIDS 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(h)(5) also provides for funding of clinical quality management activities. It states that, in addition to the 5 percent of funding allocated for administrative costs, the EMA/TGA may use for clinical quality management activities not more than the lesser of "5 percent of amounts received under the grant; or $3,000,000.

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B. HAB/DSS Expectations

The Ryan White HIV/AIDS Program places major emphasis on enhancing the quality of care for PLWHA. The complexity of HIV care—and the Act's commitment to equal access to quality care for all PLWHA—requires systematic efforts to ensure that Ryan White HIV/AIDS Program 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 Clinical Quality Management

According to the Managers' Statement in the Ryan White HIV/AIDS Program Amendments of 2000, clinical quality management programs are expected to accomplish three related purposes:

  1. Assist direct Ryan White HIV/AIDS Program-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 clinical 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 Clinical Quality Management with Program Support Spending

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

Clinical quality management activities may include but are not limited to:

  • Continuous quality improvement (CQI)

  • Use of HRSA/HAB's performance measures

  • 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 Ryan White HIV/AIDS Program 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 clinical 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 clinical quality management programs are in place.

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C. Quality Management Methods

A number of tested concepts can be used in Part A clinical 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.

EVALUATION AND CQI

CQI and evaluation are interrelated. CQI is a process to continuously improve services and outcomes. Evaluation focuses on collecting information about programs (i.e., characteristics, activities, outcomes) to determine whether objectives were met and to make program changes to improve services and outcomes.

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.

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