Transcript Developing a Quality Management Plan

Developing a Quality
Management Plan
Sheila Boyle, ACRN, MS
Process Improvement Coordinator
AIDS Program, Albany Medical College
(518) 262-4025
[email protected]
Background
•
•
•
Academic, hospital-based, HIV clinic
RWCA Titles II, III, IV
Comprehensive services
•
•
Albany, NY
Primary Care, Adherence, Case Management, Research,
Nutrition, Mental Health, Substance Abuse, Dental
1200+ patients annually
•
•
•
•
Hispanic (12%), Black (37%), White (49%);
Male (64%), Female (36%), Transgender (0.5%);
MSM (29%), IDU (17%), Heterosexual (39%);
Medicaid (40%), Medicare (20%), ADAP (19%), Private (21%)
Elements of our Quality
Management Plan
•
•
•
•
•
•
Mission Statement
Infrastructure
Annual Goals
Staff Involvement
Consumer Involvement
Evaluation and Updates
Developing a Quality Management Plan:
Mission Statement
•
•
Ensure the highest quality of patient care
Focus on clinical outcomes
Developing a Quality Management Plan:
Infrastructure
•
Core team
•
•
•
PI team
•
•
•
•
•
•
guides process
removes barriers
Multi-disciplinary
Monthly meetings
Adhoc committees as needed
Modified consensus
Ultimate decision-making authority lies with medical director
Hospital QIT
Developing a Quality Management Plan:
Annual Goals
•
•
•
•
•
•
60% with Annual Exam
90% with Visit in the last 4 Months
60% with PPD Reading
80% with Pap
70% with Secondary Prevention Intervention
Develop Mental Health Screening Tool and
Diabetes Flow Sheet
Developing a Quality Management Plan:
Staff Involvement
•
•
•
Monthly PI updates at full staff meetings
Quarterly PI updates and discussion with
providers
Interactive full-staff PI meetings 2x/year
Developing a Quality Management Plan:
Consumer Involvement
•
•
•
PI updates at each CAB (consumer
advisory board) meeting
CAB members provide feedback and
suggestions on PI projects
Several consumers on staff
Developing a Quality Management Plan:
Evaluation and Updates
•
•
•
•
Monthly review of progress toward goals
Annual review of Quality Management
Plan
Use of Addendum
Changes as needed
Developing Quality Management Plan:
Albany Med’s Process
•
•
•
IHI collaborative
Formal documentation of QM plan
Changes to plan
•
•
•
•
•
Core team
Decision-making process
Staff involvement
CAB involvement
Addendum/Updates
Lessons Learned
•
Evaluate the plan and revise prn
•
•
•
•
•
•
Goals
Decision-making process
Structure
Limit number of goals
Know when to persevere
Keep frontline staff involved