Transcript Slide 1

Quality Management Action Plan
August 9, 2009
Nanette Brey Magnani, EdD
NQC and HIVQUAL Consultant
Funded by HRSA
HIV/AIDS Bureau
Outcomes
• Become familiar with a few helpful tools and
examples
 Organizational Quality Diagram
 Timeline
 Work Plan (Gantt Chart)
• Participate in developing an Action Plan to
meet at least one of the goals for a Part D
program
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National Quality Center (NQC)
Terminology
• Quality Program
• Quality Management (Plan, Work Plan/Action
Plan)
• Quality Improvement (QI Project, QI Action
Plan/Work Plan)
• Work Plan = Action Plan
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National Quality Center (NQC)
Why?
• Create order and clarity of
 What is to be accomplished
 Who is responsible
 When
• Manage program and team process
 1-(wo)man show vs
 Shared tasks
 Doable tasks
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National Quality Center (NQC)
Gaining Commitment - Involvement
Determine:
• Who should be involved?
• How will you involve them?
 An annual planning meeting
 A series of shorter meetings that could include
piggybacking/using existing QM committee and team
meetings
 Getting input (for stakeholders who can’t attend
meetings due to time, distance, etc.)
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National Quality Center (NQC)
Making Sense: Single Organization vs
Network
Quality Infrastructure: Degrees of being
organized
 Executive/policy groups
 Quality Committees
 Part D meetings with Subcontractors
 QI Project team meetings
 Subcontractor QI meetings
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National Quality Center (NQC)
Who is responsible for QI? HELP!
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National Quality Center (NQC)
Create a Part D Quality Program Diagram
Visual Depiction of relationships that the (your)
QM Program has with other groups and
individuals in your organization or Network
and external to your organization.
Types of relationships:
 Reporting
 Supervisory
 Working
 Partnership
 Sub contractor
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National Quality Center (NQC)
The Miriam Immunology Center:
Quality Diagram of Accountability - 2010
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National Quality Center (NQC)
MDCH – Ryan White Part D Quality Management
Accountability Chart (Network-2009)
Part D
MDCH Program Coordinator
Ryan White Cross Part
Quality Committee
Part D Executive Committee
Quality Mgmt Committee
Members & Representatives from
Funded Agencies
(Meets Quarterly)
Part D Sub-Contractor Quality Mgmt
Meetings/Trainings
DMC
Horizons
UHC
Quarterly Evaluation Mtg
Bi-Monthly Mgmt Team Mtgs
Quarterly QM Committee Mtg
APM
PIDC
CHM
VNA
Wellness
DHWP
CARES
Care Services Monthly
Team Meetings
Project Challenge
QI Group Monthly Team Meetings,
Includes QI
Immunology Clinic
Bi-Monthly Mgmt Team Mtgs
Weekly Case Mgt Mtgs
Quarterly Quality Mgt
Team Meetings
Monthly Quality
Committee Meeting
Monthly Mgmt Team M
Bi-Monthly Case Mgr M
**All subcontracted agencies minimally participate in contractual Quality Improvement activities.
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National Quality Center (NQC)
Action Plan Components
Patient Care and Infrastructure
 Measures and Results
 Monitoring Goals
 Improvement Goals
 Gantt Chart: Activities, Timeline, Who
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National Quality Center (NQC)
Core
Indicator
Gynecology Exams – Patient Care
Gynecology Exam
120
100
Per cent
80
60
40
20
0
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2002
2003
2004
2005
2006
2007
syphilis screening
80
62.2
75.6
73.3
71.1
65.5
pelvic exam
87
67
67
76.7
69
56.5
abn pap followup
67
67
50
60
100
50
Gonorrhea culture
96
60
50
53
62
48
Chlamydia culture
96
60
50
53
62
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National Quality Center (NQC)
Set Patient Improvement Goal
• Increase women’s health screens by the end
of 2010:
 Increase syphilis screens from 65.5 to 80%
 Increase annual pelvic and Cervical Cancer
Screens from 56 to 80%
 Increase follow up on abnormal results from 50 to
100%
 Increase Gonorrhea and Chlamydia tests from 48
to 80%.
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National Quality Center (NQC)
 Organization Assessment Results and Improvement Priorities
Functions (All questions relate to the previous 12-months’ activities)
Score (see scoring
tool)
Quality Structure
0 1 2 3 4 5
A.1. Does the HIV program have an organizational structure to assess and
improve the quality of care?
x
A.2. Were appropriate resources committed to support the HIV quality
program?
x
A.3. Did the HIV leadership support the HIV quality program?
x
A.4. Does the HIV quality program have a comprehensive quality plan?
x
Quality Planning
0 1 2 3 4 5
B.1. Were annual goals established for the HIV quality program?
B.2. Does the HIV program have clearly described roles and
responsibilities for the HIV quality program?
B.3. Is there a document in place (i.e., workplan) to specify timelines for
the implementation of the HIV quality program?
Quality Performance Measurement
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x
x
x
0 1 2 3 4 5
C.1. Were appropriate quality indicators selected in the HIV quality
program?
x
C.2. Did the HIV program routinely measure the quality of care?
x
National Quality Center (NQC)
OA Results
Set Quality Program Improvement Goals - Example
By the end of 2009, X Grantee will achieve a more
systematized Quality Management and Quality
Improvement Program by completing the following:
• Development of a QM Plan and Annual QI Action Plan
(also improves goal setting)
• Utilizing a team approach for planning and conducting QI
Projects
• Increasing staff members’ (clinical and non clinical)
knowledge and skills in QI through training groups of staff
members
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National Quality Center (NQC)
Develop Your Action Plan
The Action Plan should include:
 Goal
 List of key activities
 Identification of who is responsible for completing or
overseeing the completion of activities
 When the activities are to be carried out and
completed during the year
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National Quality Center (NQC)
Timeline
• Select major activities of QM Committee
• Create 12-18 month timeline
• Uses
 Gives perspective on Committee’s work
 Guides development of agendas
 Guides development of more specific Action Plan
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National Quality Center (NQC)
HIV CQI Committee
Annual QM Timeline 2009-2010
Review Annual
PM report
Id QI priorities
(Jan.Feb March) April
May
Develop QM Plan
and Work Plan;
feedback at July
CQIC
June
July
August
QI project update;
Determine data
needs and PMs for
2010; Approve QM
Plan / Work Plan
September
October
November
Evaluate Quality
Program and Update
Quality Management
Plan . Discuss QI
Project Results and
sustaining results
December
January, 2010
CQI Committee meets quarterly (April, July, October, January)
------------------------------------QI project teams meet throughout the year--------------------------------------------
RDR due March
15th
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QI Project Teams
Meet
National Quality Center (NQC)
Goal: To implement a systematic, effective
HIV Quality Program to improve patient care.
Completed by 2009
Who
Jan
2009 Meet quarterly
Develop QM Plan.
 Part 1: Description
 Part 2: Annual QI Work Plan
Update QM plan (revise)
CQIC
X
QM Plan
sub group
Review Annual Quality Performance
Measurement Report
Identify QI priorities and Projects
CQIC
Monitor implementation of plan
(seek feedback from CQIC)
Set quarterly meeting schedule
Evaluate QM Program
QM Plan
sub group
CQIC
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Feb Mar Apr May June July Aug Sept Oct Nov Dec
X
X
X
X
X
X
X
CQIC
Jan
2010
X
X
X
Jan
2010
X
X
X
National Quality Center (NQC)
Goal: Increase women’s health screens by the end of
2010: syphilis, pelvic and CCS, and Gon, Chla. to 80%,
and follow up on abnormal results to 100%
Completed by 2010-2011
Activities
Who
Jan Fe
Select team membership
CQI Committee
Mar Apr
May June July
Aug
Sept
Oct
Nov
Dec
X
Project teams
Convene team. Discuss data.
Complete flow diagram to
determine if one team is sufficient
to address all measures.
Women’s Health Screening
Conduct a causal analysis and
determine key causes.
Set QI Project goals. Determine
intervention(s) and agree on plan.
Implement QI Project plan.
(PDSAs)
Report QI Project results to CQIC.
Develop monitoring plan to sustain
results.
Approve and monitor plan.
QI Project Team Training
Training/Meeting 1
Training/Meeting 2
Training/Meeting 3, 4
Training/Meeting 5, 6
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Pat Team Lead
Pat Team Lead
QI team: Sandy,
Robert, Felicia,
Jane
QI team
X
X
X
QI Team
XXX XXX XXX
QI Team
QI Team
X
X
Jan.
2011
CQIC
QI Project Teams,
HIVQUAL
Consultant
X
X
X
X
X
X
National Quality Center (NQC)
Facilitator helps group:
1. Clarify the goal.
2. List activities necessary to meet the goal.
3. Order them sequentially to the extent
possible.
4. Write activities on a Gantt Chart.
5. Determine who is responsible.
6. Determine when activities can be
accomplished.
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National Quality Center (NQC)
Let’s Try Your Example!
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National Quality Center (NQC)
RW Part D Network Example
QM and Staff Training Timeline for 2009 - 2010
Annual Action Plan
-Review agency’s data
-Select QI Projects
-Review and edit PDSA
worksheet and fill out
-Brainstorm key activities for
QM Program and complete
draft of Action Plan
-Brainstorm Training topics
April
May
Agency QI project update.
Use of PDSA worksheets.
Training: Review key
components of a QM Plan
and Action Plan;
participants exchange QM
Plans and give feedback.
June
July
August
QI project update using
Storyboard as first draft.
Determine performance
meas, data and
CAREWare needs for
2010.
September
October
November
Share plans for
sustainability of CQI
projects and results.
December
January, 2010
----------------------------------- QI project teams meet throughout the year--------------------------------------------
HRSA: CLD
reports due 7/1
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CLD reports
due
Present
Storyboards
to Executive
Committee
National Quality Center (NQC)
NQC Resources
• Action Planning Guide
Strategies for
Implementing your
Quality Improvement
Activities |
http://nationalqualitycenter
.org/index.cfm/5659
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National Quality Center (NQC)
Contact Information
Nanette Brey Magnani, EdD
National Quality Center and HIVQUAL
Consultant
[email protected]
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National Quality Center (NQC)
National Quality Center (NQC)
212-417-4730
NationalQualityCenter.org
[email protected]
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National Quality Center (NQC)