Transcript Slide 1

National Technical Assistance Call
June 5th, 2006
How to write and update a Quality
Management Plan?
“How can you make this topic entertaining
and keep everyone from falling asleep?”
Clemens Steinböck, MBA
Funded by HRSA
HIV/AIDS Bureau
What are my options?
• Use pictures
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What are my options?
• Use humor
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What are my options?
• Use my kids
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What are my options?
or
• Use the audience…
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Polling
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5. How would you define a Quality
Management Plan?
a) A workplan outlining annual QI activities, not
describing the QM infrastructure
b) A written document that outlines the Quality
Management Program
c) Same as Quality Management Program
d) Represents the organizational structure of
the formal HIV Quality Program
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6. Which statement about the Quality
Management Plan is TRUE?
a) A QI plan should not reference JCAHO and its
framework for quality improvement
b) A Title III/IV QM plan should only address Ryan
White funding requirements for quality
c) An up-to-date QM Plan is an expectation for Title
III and Title IV grantees
d) A complete QM Plan needs to have at least 15
pages or more
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7. Which of the following elements should
be included in a Quality Management Plan?
a)
b)
c)
d)
e)
f)
g)
h)
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Quality statement
Quality improvement infrastructure
Performance measurement
Annual quality goals
Participation of stakeholders
Evaluation
All of the above
None of the above
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8. Which of the following rules to write a
QM Plan is NOT correct?
a) If you have not touched your plan in the last 6
months, bring it to the next QM meeting
b) 80% planning, 20% writing
(an old software programming rule)
c) Do not reinvent the wheel, use an established
framework to get started
d) The ultimate measure of a good plan is that only
the entire planning group agrees
e) A perfect QM plan is probably written by the
consultant (and nobody knows anything about it)
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What we will cover:
•
•
•
•
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Quality Management Plan Quiz/Poll
Definitions of Terms
Elements of a Quality Management Plan
10 Rules by Clemens
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Definitions of Terms
Quality Management Program: The term
‘quality management program’ encompasses
all grantee-specific quality activities, including
the formal organizational quality infrastructure
(e.g., committee structures with stakeholders,
providers and consumer) and quality
improvement related activities (performance
measurement, QI project and QI training
activities).
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Definitions of Terms
Quality Management Plan: A Quality
Management Plan is a written document that
outlines the grantee-wide HIV Quality
Program, including a clear indication of
responsibilities and accountability,
performance measurement strategies and
goals, and elaboration of processes for
ongoing evaluation and assessment of the
Program.
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TA Resource: Quality Management Program
Assessment Tool
• Title-specific Organizational
Assessment Tool of the HIV
Quality Management Program
• Categories of assessment
questions with detailed
scoring instructions
(score 0 – low; score 5 - high)
• www.HIVQUAL.org
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TA Resource: Quality Management Plan
Checklist
• Checklist for the review of an
HIV-specific Quality Management
Plan
• Elements include:

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Quality statement, Quality
infrastructure, QM Plan
implementation, Performance
measurement, Annual quality
goals, Participation of
stakeholders, Evaluation,
Capacity Building, Process to
update QM Plan,
Communication, Formatting
www.NationalQualityCenter.org
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Elements of a Quality Management Plan
•
•
•
•
•
•
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Quality statement
Quality improvement infrastructure
Performance measurement
Annual quality goals
Participation of stakeholders
Evaluation
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Part 1: Quality Statement
What do we want to be?
• brief purpose/mission statement describing
the end goal of the HIV quality program to
which all other activities are directed
• assume an ideal world and ask yourselves,
"What do we want to be for our patients and
our community?“
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Part 1: Quality Statement
Tips:
• Be brief
• Be visionary
• Include internal and external expectations
• Make references to Ryan White legislative
requirements on quality management
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Part 2: Quality Improvement Infrastructure
How are we organized?
Leadership
Who is responsible for the grantee-wide quality improvement
initiatives?
Accountability
Who are the major stakeholders? What are their expectations for the
quality management program?
Quality committee(s) structure
Who serves on the internal and external quality committee(s)? Who
chairs the HIV quality committee(s)? When will the quality committee
meet to assess progress and plan future activities? How will QI
activities be communicated?
Resources
What are the resources for the QM Program? Staffing?
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Part 2: Quality Improvement Infrastructure
Tips
• Not more than 3-5 pages (not every detail is
needed)
• Avoid naming individuals (just job functions)
• List internal and external stakeholders
• List linkages
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Part 3: Performance Measurement
How will we assess progress?
• identify and quantify the critical aspects of
care and services provided in your HIV
program
• develop indicators and measure the progress
of the QM Program
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Part 3: Performance Measurement
Tips
• include the process for reviewing and
updating the indicators (who/when/how)
• include a portfolio of process, outcome and
satisfaction measures
• include strategies how to report and
disseminate results and findings
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Part 4: Annual Quality Goals
What are the priorities for the quality program?
• Quality goals are endpoints or conditions toward which
quality program will direct its efforts and resources
• Develop a annual goals, the following three criteria can
be helpful:
 Frequency: How many patients/clients received and how many
did not receive the standard of care/services?
 Impact: What is the effect on patient health if they do not
receive this care/services?
 Feasibility: Can something be done about this problem with the
resources available?
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Part 4: Annual Quality Goals
Tips
• pick only a few measurable and realistic goals
annually (not more than 5)
• use a broad range of goals
• establish thresholds at the beginning of the year
for each goal
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Part 5: Participation of Stakeholders
How will providers, consumer and other
stakeholders be involved in the QM
Program?
• Engage internal and external stakeholders
• Communicate information about quality
improvement activities
• Provide opportunities for learning about quality
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Part 5: Participation of Stakeholders
Tips
• List internal and external stakeholders and their
functions/responsibilities
• List proposed training opportunities for staff and
providers
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Part 6: Evaluation
How will we evaluate our overall performance as a
program?
• Evaluate quality infrastructure effectiveness
 Was the quality committee effective in its efforts to improve the
quality of HIV care/services? Does the quality infrastructure
require any changes?
• Evaluate QI activities
 Were annual quality goals for quality improvement activities
met? Did the implementation of the annual work plan go as
planned?
• Performance measures
 Were the measures appropriate to assess the clinical and non-
clinical HIV care? Are the results in the expected range of
performance?
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Part 6: Evaluation
Tip
• Detail when and who is performing the
evaluation
• Compare annual QI goals with year-end results
• Use findings to plan next year’s activities; learn
and respond from past performance
• Routinely use organizational assessment tools
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The 10 QM Plan Rules:
Rule 1 - Size does not matter.
Rule 2 – Do not reinvent the wheel, use established
frameworks to get started.
Rules 3 – 80% planning, 20% writing (old software
programming rule).
Rule 4 – ‘Steal Shamelessly, Share Senselessly.’
Rule 6 – Be inclusive, even it takes longer to get your
final QM plan.
Rule 5 – A few visionary annual goals are better than
plenty of useful ones.
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The 10 QM Plan Rules:
Rule 7 – If you have not touched your plan in the last
6 months, bring it to the next quality committee
meeting.
Rule 8 – A perfect QM plan is probably written by the
external consultant (and nobody knows anything
about it).
Rule 9 – Perfect plans are only as good as its
implementation.
Rule 10 – Get Started.
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Contact Information
Clemens Steinbock
National Quality Center (NQC)
NYSDOH AIDS Institute
90 Church Street—13th Floor
New York, NY 10007-2919
888-NQC-QI-TA
[email protected]
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