Quality Management 101: Performance Measurement and Quality Projects

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Quality Management 101Performance Measurement
and Quality Projects

• Tuesday, July 11th, 2006, 930am 1000pm
• Facilitator Nanette Brey Magnani, EdD
• HIVQUAL Consultant
• NYSDOH AIDS Institute

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Workshop Agenda

• Outcomes
• To understand how to meet the NYS standards of
  Performance Measurement and Quality Improvement
  Projects by
• Understanding basic knowledge and developing
  basic skills in developing and selecting
  indicators, data collection and sampling, and
  data analysis.
• Understanding basic knowledge and developing
  basic skills in setting improvement goals,
  analyzing causes, and applying the PDSA
  methodology to planning a QI project.
• Identifying existing elements of QM Plans that
  describe HIV programs systems for measuring
  performance and making improvements.

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Time Activities

• 930 Registration
• 1000 Welcome. Review agenda.
• 1030 Summary of QM 101 Session 1 2.
• 1045 Measuring Performance
• 1200 Working lunch (Demo of HIVQUAL software.)
• 1245 Data Analysis and Goal Setting
• 130 QI Project Planning and PDSA
• 330 Summation Review sections of QM Plans
• Next Steps. Evaluation
• 400 Adjourn.

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Summary QM 101Introduction and Infrastructure

• Quality Improvement Principles
• NYS Standards
• Organizational Assessment
• Quality Management Plan
• HIVQUAL Model and Philosophy

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QI Principles

• Success is achieved through meeting the needs of
  those we serve.
• Most problems are found in processes, not in
  people. 
• Do not reinvent the wheel Learn from best
  practices.
• Achieve continual improvement through small,
  incremental changes.
• Actions are based upon accurate and measured
  data.
• Infrastructure enhances systematic implementation
  of improvement activities.
• Set Priorities and Communicate clearly.
• Quality is achieved through Teamwork.

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NYS Quality Program Standards

• A) Infrastructure for HIV Quality Program
• B) Staff Involvement in Quality Improvement
  Activities
• C) Performance Measurement
• D) Quality Improvement Projects
• E) Consumers Involvement

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Organizational Assessment

• Tool to assess the HIV-specific quality structure
  and activities
• Annual assessment for all HIVQUAL sites
  benchmarking opportunity
• Share program strengths and identify
  opportunities for improvement

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Key Parts of a Quality Management Plan

• 1. Quality statement
• 2. Quality improvement infrastructure
• 3. Performance measurement
• 4. Annual quality goals
• 5. Stakeholder Development
• 6. Consumer Involvement
• 7. Evaluation
• 8. Workplan

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Philosophy of HIVQUAL
Infrastructure
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HIVQUAL Model
Plan
Act
Do
Study
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Performance Measurement Indicators, Sampling,
Data Collection and Planning

• NYS Standard
• 'Performance measurement should include clearly
  defined indicators that address clinical, case
  management and other services as prioritized by
  the program. A plan for follow-up of results
  should be outlined.'

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Why Measure?

• Separates what you think is happening from what
  is really happening
• Establishes a baseline Its ok to start out with
  low scores!
• Helps to avoid putting ineffective solutions in
  place
• To monitor improvements and prevent slippage
• Indicates whether changes lead to improvements
• Allows for comparing performance across sites

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Measuring performance

• Steps to measure performance
• 1. Select a quality of care indicator.
• 2. Define the measurement population.
• 3. Define the measure.
• 4. Create a data collection plan.
• 5. Develop data collection tools and
  instructions.
• 6. Train medical record abstractors.
• 7. Run a pilot test.
• 8. Collect data.
• 9. Analyze data and plan QI activities.
• 10. Display and distribute data.
• 11. Evaluate the measurement
• process and determine how to
• improve it.

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Exercise HIVQUAL Indicator Table

• Small group instructions
• Review the HIVQUAL Indicator Table. In the
  column to the right of the indicators write in
  the total number of group members who
• currently collect data on the indicator
• are able to collect data, i.e., data exists in
  chart, EMR
• data does not exist

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Eligible Patients/Sample (pts seen in the clinic
twice in the last 12 months with at least one
visit in the last 6 months)
Denominator (pts with CD4 counts lt 200)
Numerator (pts with prescribed PCP prophylactic
therapy)
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Constructing a Sample Definitions

• Sampling allows teams to make inferences about a
  total population based on observations of a
  smaller subset of that group
• Oversampling may be required if a measurement
  pertains exclusively to one group within a
  population

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Constructing a Sample Methodology

• Define the selection criteria.
• Gender
• Age
• Patient condition
• Treatment status
• Identify eligible cases.
• Randomly select cases.

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HIVQUAL Indicator Definition

• HIVQUAL eligibility - patients seen twice within
  the calendar year with at least one visit in the
  last 6 months
• Example
• Numerator ( of pts with prescribed PCP
  prophylactic therapy)
• __________________________________________________
  ____
• Denominator ( of patients 18 years of age or
  older
• with CD4 counts lt 200 cells/mm3 and who
• were seen twice in 2005 with one visit in the
  
• last 6 months)

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Step 2 Determine Total Number Eligible Patients
for Denominator
Total Patients 217
Female Patients 91
Male Patients 126
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Create a data collection plan

• Decide on sampling plan (sample size, identify
  eligible records, draw a random sample)
• Develop data collection instructions
• Train data abstractors

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Step 4 Generate Random Number List for Sampling
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Step 4 with www.randomizer.org
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Collect and Report Data

• Enter data and run pilot test (adjust after a few
  records)
• Inform other staff of the measurement process
• Remain available for guidance
• Enter all the data.
• Validate results.
• Display and distribute data

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www.hivqual.org or www.hivguidelines.org

• Contact Information
• If you need help operating the HIVQUAL3 Software
  once you've read the ReadMe file and the User's
  Guide, please contact the HIVQUAL Data Analyst,
  Chris Wells, at 212-417-4538 (cgw02_at_health.state.
  ny.us) or the HIVQUAL Data Manager, Lily Jiang,
  at 212-417-4539 (llj01_at_health.state.ny.us).
• For questions related to the HIVQUAL Project,
  please contact the Program Manager, Matthew
  Cunningham, at 212-417-4509 (msc07_at_health.state.ny
  .us).

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• HIVQUAL Basic Project Information
• 2003 and 2004 National HIVQUAL Performance Data
  Aggregate Report
• HIVQUAL Publications
• HIVQUAL Organizational Assessment Tool
• HIVQUAL3 Software and Users Guide
• Deadline for 2005 HIVQUAL Data Submission March
  15, 2006
• Order HIVQUAL3 SoftwareDownload HIVQUAL3
  Upgrade Patches Download HIVQUAL3 Reference
  Materials

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HIVQUAL Software Demonstration
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D) Quality Improvement Projects

• 'Quality Improvement activities should be
  conducted based on performance data results.
  Specific quality improvement projects should be
  undertaken which include action steps and a
  mechanism for integrating change into routine
  activities. Quality improvement teams should
  include cross-functional representation.'

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Exercise instructions Review chart with
aggregate data for 2003-2004 including national
benchmarking data.

• Using the following criteria, select 3-4
  priorities for improvement for the upcoming
  year.
• Change in performance over time
• FIF
• Frequency How many patients are affected?
• Impact What is the impact? Clinical, other
• Feasibility How feasible is it to make a
  change?
• Describe your rationale when reporting out.
• Set at least one improvement goal that
• Is measurableincreases, decreases
• Has time frame
• Includes baseline data, i.e., to increase
  fromto.

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HIVQUAL Model
Plan
Act
Do
Study
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HIV Quality Program Teamwork

• HIV Quality Committee
• Plan, Implement and Evaluate Quality Program
• QI Project Team (multidisciplinary, include key
  staff those involved and affected by the
  process)
• Collect data (if necessary)
• Investigate the process
• Conduct PDSAs
• Systematize changes
• Consumer Involvement
• Consumer Advisory Board, Community Boards
• HIV Quality Committee
• Patient Satisfaction Surveys, Focus groups

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Making Improvements

• Model consists
• A) three questions (goal, measure, change) to
  form context for improvement
• B) Plan-Do-Study-Act (PDSA) Cycle to structure
  tests

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What is our Improvement Goal?

• Understand the current situation
• Underlying causal analysis
• Use data to define
• Establish measures
• We want to see an increase/decrease in the
  number of patients who....

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What changes can we make that will result in
improvement?

• PDSA cycle
• Plan what makes sense, based on our current
  knowledge?
• Do try it out and measure the results.
• Study what does our trial show us?
• Act another cycle? Alter the plan? Expand
  implementation?

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Tips for PDSA Cycles

• Test on small scale Use shorter cycles of
  changes to accelerate rate of improvement (What
  can you test by next week)
• Build knowledge sequentially Create flow of
  ideas, then emphasize implementation (increase
  the frequency of tests)
• Useful, not perfect data
• Adoption of existing knowledge (Steal
  shamelessly, Share senselessly)

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Example for PDSA Cycle
Use of flowsheet will improve care to known
standards
DATA
Cycle 1E Implement and monitor the
standards
Cycle 1D Revise and test tool with all
pts for one week
Cycle 1C Present refined the tool to all 3
providers and document feedback
Cycle 1B Revise tool and test with Johns
pts next Monday
Cycle 1A Adapt new adherence screening tool and
test with one of Joannes pts
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GYN QI Project

• Improvement Goal
• Site 1 64 to 80
• Site 2 64 to 85
• Site 3 52 to 85
• Site 4 36 to 95
• Problems and Underlying Causes
• Failure to keep appointment
• Wait time in clinic
• Provider unaware of patients pap schedule
• Large transient population

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GYN QI ProjectResults
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Exercise Develop a QI Plan to improve GYN rates.

• Instructions
• Use the QI Project Plan template.
• Set your goal.
• Make a prediction.
• Identify at least three PDSAs.
• Include how you will measure the changes.
• Include necessary tasks to complete the plan.

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Summation Next Steps. QM Plan/Annual QI
Workplan Example

• HIV Quality Program. II. Yearly Work Plan- 2006
• Members
• Members of the HIV Quality Committee for 2006
  Dr. .(Medical Director of MHHC), Mr. (Director
  of HIV Services), Mr. ..Physician Assistant),
  Dr. ..(Medical Director at Walton), Ms. .(
  Mental Health), ..(Medical Case Manager/
  Adherence Counselor).
• Schedule
• Meetings for this year cycle will be scheduled at
  9 am at ..Ave. on the following dates
• April 12th, May 3rd, (May 10th -PI Meeting at.),
  June 14th, August 9th, October 11th, December
  13th, February 14, 2007 (yearly planning meeting)
• If conflicts arise, meeting dates can be
  rescheduled. After the Committees first official
  year meetings can consistently meet every other
  month or as needed.

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• Project Selection
• The Committees PI projects will be chosen by the
  committee based on low performing CADR and
  HIV/QUAL data as well as other identified needs
  to improve HIV care.
• For 2005, the lowest 5 performing HIV/QUAL data
  were
• MAC prophylaxis
• Mental Health Assessment
• Pap Smears
• HIV monitoring q 4mo.
• PPDs placed/ read last 24 mo.
• For the Ryan White Title III work plan year of
  7/1/05- 6/30/06 the low performing goal estimates
  were
• Nutrition visits
• Oral Health
• PPD
• Pap Smears

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• The identified projects for the 2006 year will
  be
• Project in progress Systems project- URS
  Training-
• Project in progress Quality project- HIV
  Monitoring- ..
• Phase One complete
• Phase Two in progress (completed by Aug. 30th)
• New Project Pap Smear- ..
• Workgroup members
• New Project MH Assessment- .
• Workgroup members ..
• Timeline
• The timelines will be set by the project
  workgroup leaders.
• Pap Smear and MH Assessment projects will be
  started by June 1st and completed no later than
  September 30th.
• The Third Phase of the HIV Monitoring project
  will begin September 1st.
• Any additional projects can be started as
  resources allow as deemed by appropri

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Thank you for your participation.Please
complete the evaluation forms and hand them in.