Transcript Slide 1

Quality Institute Session 1
What is Quality Improvement?
What are the Quality Expectations from HAB?
Aug 26, 2008
Clemens Steinbock, MBA
Director, National Quality Center
Funded by HRSA
HIV/AIDS Bureau
Agenda
- Opening Remarks
- Overview and Introduction
- Quiz – Group Activity
- Principles of Quality Improvement
- Scenario – Group Activity
- HAB Expectations on Quality
- QI Resources
- Evaluations and Wrap-up
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National Quality Center (NQC)
“How can you make this topic
entertaining and keep
everyone from falling asleep?”
3
National Quality Center (NQC)
What are my options?
• Use humor
4
National Quality Center (NQC)
What are my options?
• Use my kids
5
National Quality Center (NQC)
What are my options?
or
• Use the audience… via the Audience
Response System
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National Quality Center (NQC)
Quiz
Funded by HRSA
HIV/AIDS Bureau
1) What does CQI stand for?
a)
b)
c)
d)
8
Community Quality Initiative
Case Management Quality Ideas
Continuous Quality Improvement
Circular Quantum Invention
National Quality Center (NQC)
2) Why does Quality Improvement become
increasingly important in health care?
a) Quality Improvement has been proven to be
successful
b) Increasing requirements by regulatory
agencies
c) Increasing accountability by programs for
the quality of services
d) All of the above
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National Quality Center (NQC)
3) What is the main difference between
Quality Assurance and Quality Improvement?
a) Quality Assurance uses mainly a team
approach
b) Quality Improvement focuses on statistical
outliers for improvements
c) Quality Assurance and Quality Improvement
is practically the same
d) None of the above
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National Quality Center (NQC)
4) What is the most important principle for
Quality Improvement? Quality Improvement
focuses on…
a)
b)
c)
d)
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Individual performers
Routine measurement of performance
Training of providers
System’s issues
National Quality Center (NQC)
5) Which of the following statement by HAB is
INCORRECT?
a) QM programs need to look beyond clinical services to
consider both supportive services and outcomes
b) QM programs assess the extent to which HIV health
services are consistent with the most recent Public Health
Service guidelines
c) The primary focus of the QM program is on performance
measurement to assess clinical and non-clinical services
d) Quality is the degree to which a health or social support
service meets or exceeds established professional
standards and user expectations
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National Quality Center (NQC)
6) HAB describes the following characteristics
of Quality Management Programs. Which
ones are CORRECT?
a) Be a systematic process with identified leadership,
accountability and dedicated resources
b) Use data and measurable outcomes to determine
progress toward relevant, evidenced-based benchmarks
c) Focus on linkages, efficiencies and client expectations in
addressing outcome improvement
d) Ensure that data are fed back into the quality
improvement process to assure that goals are
accomplished
e) All of the above
f) None of the above
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National Quality Center (NQC)
7) The following performance data report is
presented: PPD 95%, GYN 85%, and PCP
Prophylaxis 55%. You advise the program to
continue to measure…
a) only PCP Prophylaxis
b) GYN and PCP Prophylaxis
c) All three indicators
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National Quality Center (NQC)
8) The results of an adherence QI project are
presented after 10 months of work, improving the
rate to 98% and it was kept between 95%-100% for
the last 4 months. You advise the program to…
a) Discontinue routine measurements
b) Switch to quarterly measurements
c) Keep monthly measurements
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National Quality Center (NQC)
9) Due to the high rate of Mental Health screening
(95%), the QI team stopped meeting but continued
to measure the rate monthly. Recently the score
declined. When should the MH QI team to re-start?
a) 90%
b) 80%
c) 70%
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National Quality Center (NQC)
Couple more questions…
Funded by HRSA
HIV/AIDS Bureau
What is your professional background?
0%
0%
0%
0%
0%
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1.
2.
3.
4.
5.
Clinical Provider (MD, NP, PA)
Nurse
Case Manager/Social Worker
Administrator
Other
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National Quality Center (NQC)
How do you rate your own quality improvement
knowledge?
0%
0%
0%
0%
0%
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1.
2.
3.
4.
5.
Novice
Beginner
Intermediate
Proficient
Expert
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National Quality Center (NQC)
How do you rate your HIV Quality Management
Program?
0%
0%
0%
0%
0%
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1.
2.
3.
4.
5.
Not existing
Beginning
Sufficient
Good
Excellent
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National Quality Center (NQC)
Quality Improvement
Principles
Clemens Steinbock, MBA
212.417.4730
[email protected]
NationalQualityCenter.org
Funded by HRSA
HIV/AIDS Bureau
Success is achieved through meeting the
needs of those we serve.
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National Quality Center (NQC)
Most problems are found in processes,
not in people.
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National Quality Center (NQC)
Do not reinvent the wheel – Learn from
best practices.
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National Quality Center (NQC)
Learn through small, incremental changes
to achieve continual improvements.
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National Quality Center (NQC)
Actions are based upon accurate and
measured data.
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National Quality Center (NQC)
Infrastructure enhances systematic
implementation of improvement activities.
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National Quality Center (NQC)
Set Priorities and Communicate clearly
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National Quality Center (NQC)
Balance between Data Collection and
Quality Improvement Activities
Infrastructure
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National Quality Center (NQC)
‘QI is not QA’
Quality Assurance
Quality Improvement
Motivation
Measuring compliance with
standards
Continuously improving
processes to meet standards
Means
Inspection
Prevention
Focus
Individuals, “bad apples”
Processes and Systems
Responsibility
Few
All
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National Quality Center (NQC)
Three Faces of Quality Improvement
Aspect
Improvement
Accountability
(Accreditation)
Clinical
Research
Aim
Improvement of care
Comparison, choice,
reassurance, spur
for change
New knowledge
Test observability
Test observable
No test, evaluate
current performance
Test blinded
Sample size
“Just enough” data,
small sequential
samples
Obtain 100% of
available, relevant,
data
“Just in case” data
Testing strategy
Sequential tests
No tests
One large test
Solberg, Mosser, and McDonald, Journal on Quality Improvement. March 1997, Vol.23, No. 3.
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National Quality Center (NQC)
HAB’s Working Definition of Quality
“Quality of care is the degree to which
health services for individuals and
populations increase the likelihood of
desired health outcomes and are
consistent with current professional
knowledge.”
Institute of Medicine. Medicare: A Strategy for Quality
Assurance. Vol. 1. (1990)
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National Quality Center (NQC)
In 1601, James Lancaster successfully
conducted an experiment to illustrate the
effectiveness of lemon juice to prevent scurvy.
When did the British Navy adopt this treatment?
1.
2.
3.
4.
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1602
1689
1757
1796
National Quality Center (NQC)
Treatment of Scurvy
• Stephen J. Bown - Scurvy:
How a Surgeon, a Mariner,
and a Gentleman Solved the
Greatest Medical Mystery of
the Age of Sail; St. Martin's
Press, 2004
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In 1601 lemon juice, as a protective against scurvy, is
recorded by James Lancaster.
In 1612, Woodall recommended citrus fruit for
protection against scurvy on sea voyages.
In 1753 James Lind published A Treatise on the
Scurvy which portrays his experiment on-board the
ship Salisbury in 1747.
From 1772 to 1775 sailors on historic voyages with
Captain James Cook remained free from scurvy.
In 1796 lemon juice was officially introduced in the
British Navy as a prophylactic against scurvy.
In 1865 British Board of Trade adopted the policy for
the merchant marine.
National Quality Center (NQC)
How long did the NIH take to recommend the
treatment of ulcer as suggested by Dr. Marshall
in his 1984 Lancet Article?
1.
2.
3.
4.
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2 years
5 years
10 years
20 years
National Quality Center (NQC)
Treatment of Ulcer – Marshall
Timetable:
1979: Dr. Robin Warren, pathologist at Royal
Perth Hospital, Australia found bacteria in
stomach of patients
1981: Dr. Barry Marshall starts residency
1982: Marshall cultivates bacteria:
Helicobacter pylori, 100% in Duodenal
Ulcer and 77% in Gastric Ulcer
1984: first publication in Lancet; presents
treatment of ulcer with common antibioticum
1994: National Institute of Health
recommends treatment of ulcer as suggested
by Dr. Marshall
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National Quality Center (NQC)
In a recent article in the Journal of Quality
Improvement 92 QI projects were compared.
What was the timeframe from problem
identification to completion of first pilot?
1.
2.
3.
4.
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23 days
60 days
397 days
504 days
National Quality Center (NQC)
Survey of 92 Quality Improvement Projects
in Journal of Quality Improvement
• Alemi F, Safaie F, Neuhauser
D. “A Survey of 92 Quality
Improvement Projects.”
Journal of Quality
Improvement 2001, 27(11):
619-632
•
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504 days from problem identification to
completion of first pilot
397 days from first team meeting to the
end of first cycle
75 days to describe current situation in
flowchart
62 days for data collection if change
was improvement
National Quality Center (NQC)
Model for Improvement
How can we accelerate change and
improvements in HIV programs?
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National Quality Center (NQC)
Model for Improvement
What are we trying
to accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Model
for
Improvement
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Act
Plan
Study
Do
National Quality Center (NQC)
Model for Improvement
What are we trying
to accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
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National Quality Center (NQC)
Model for Improvement
What are we trying to
accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
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National Quality Center (NQC)
Model for Improvement
What are we trying to
accomplish?
How will we know
that a change is an
improvement?
What change can we
make that will result in
improvement?
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National Quality Center (NQC)
The PDSA cycle
for learning and improvement
Act Objective
Plan
What changes
are to be
made?
Next cycle?
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Study Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
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Carry out the plan
Document problems
and unexpected
observations
Begin analysis of
the data
National Quality Center (NQC)
PDSA Cycle to incorporate the use of a new
CM form
Improve
Access to HIV
Primary Care
A P
S D
Introduce new
CM Intake/
Assessment
Form
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A P
S D
Cycle 1E: Implement and
monitor the standards
Cycle 1D: Revise and test tool
with all clients for one week
Cycle 1C: Present refined tool to all 3
case managers and document feedback
Cycle 1B: Revise tool and test with Karl’s
clients next Monday
Cycle 1A: Adapt new CM form and test with one of Joanne’s
patients
National Quality Center (NQC)
Tips for PDSA Cycles
• “What change could you implement by next
Tuesday?”
• Use the “Rule of 1”:
 1 facility
 1 office
 1 provider
 1 patient
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National Quality Center (NQC)
Tips for PDSA Cycles
•
•
•
•
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Volunteers at first
Useful, not perfect, data
Use “huddles” to report
Learn from others (‘Steal shamelessly,
Share senselessly’)
National Quality Center (NQC)
References
• Moen, Ronald, Thomas Nolan; “Process Improvement” Quality
Progress, 1987, p62
• Langley, Gerald, Kevin Nolan and Thomas Nolan; “The
Foundation of Improvement,” Quality Progress, June 1994, p. 81
• Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and
Lloyd Provost; “The Improvement Guide” San Francisco, CA;
Jossey-Bass, 1996
• Nolan, Kevin; “ASQs Accelerating Change Collaborative Series:
A Challenge for
Industry,” Quality Progress, Jan 1999, p55
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National Quality Center (NQC)
HRSA’s 9-Step Model to Quality
Goal of Manual:
•
•
•
provide the tools to develop and
implement a quality management
program
outline a step-by-step process that can
be applied in any care setting
applicable for both the experienced and
non-experienced grantee
Developed by HIV/AIDS Bureau
Quality Institute
49
National Quality Center (NQC)
HRSA’s 9-Step Model to Quality
1.
Commit Leadership & Supportive Organizational
Structure


2.
Establish Quality Management Plan


3.
Establish Quality Committee to oversee the QM program
Develop an organizational QM plan which delineates goals and
objectives for the QM program
Determine Performance Measures & Collect Data
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Establish support of program leadership for Quality Management
Delineate specific QM responsibilities of staff
Based on QM priorities, develop/adopt indicators to measure
performance
Determine method of data collection and collect data
National Quality Center (NQC)
HRSA’s 9-Step Model to Quality
4.
Analyze Data
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
5.
Develop Project-Specific CQI Plan
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6.
Establish project-specific QM team to improve specific aspects of
care/services
Develop timeline for reporting findings and improvement
Study and Understand the Process
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Analyze data and review the results
Identify areas where additional data is required
Utilize QI tools and techniques to understand the process
Report progress to senior leadership and staff
National Quality Center (NQC)
HRSA’s 9-Step Model to Quality
7.
Develop and Implement an Improvement Plan
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
8.
Re-measurement
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
9.
Re-measure indicator after change has been
implemented.
Determine need for and/or level of re-measurement on an
ongoing basis.
Celebrate Success

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Identify potential solutions to make improvement to the
systems of care.
Try a small test of change and analyze results.
Communicate results of the project to all levels of the
organization
Congratulate team in public forum
National Quality Center (NQC)
References
• HAB Quality Management Manual, HRSA HIV/AIDS
Bureau website; hab.hrsa.gov/tools/QM
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National Quality Center (NQC)
Scenario – Group
Exercise
Clemens Steinbock, MBA
212. 417 4730
[email protected]
NationalQualityCenter.org
Funded by HRSA
HIV/AIDS Bureau
HAB Quality
Expectations
Clemens Steinbock, MBA
212. 417 4730
[email protected]
NationalQualityCenter.org
Funded by HRSA
HIV/AIDS Bureau
Update: Ryan White HIV/AIDS Treatment
Modernization Act of 2006 – PL 109-415
• Reauthorized for 2006 - 2009 which sunsets 9/30/09
• Increased focus on living HIV and AIDS cases over the last
calendar year
• Increased focus on expenditures for core medical services
• Increased focus on coordination and integration of care and
prevention at federal, state and local levels
• Significant changes include: Part A eligibility definition, funding
formulas, hold harmless percentages, annual sample audits,
biannual reports to congress on funds expended, consequences
for failure to comply
See a Side-by-side comparison at
www.kff.org/hivaids/upload/7531-03.pdf
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National Quality Center (NQC)
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
• “The chief elected official/ grantee… 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
guidelines for the treatment of HIV disease 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”
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National Quality Center (NQC)
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
• “RWCA grantees are directed to establish clinical
quality management programs to …”
• “assess the extent to which HIV health services are
consistent with the most recent Public Health Service
(PHS) guidelines…”
• “develop strategies for ensuring that such services are
consistent with the guidelines for improvement in
access to and quality of HIV health services”
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National Quality Center (NQC)
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
“RWCA grantees are directed to establish clinical quality
management programs..” which include:
 Development of a comprehensive clinical quality management
infrastructure, including routine QM meetings with crossfunctional representation
 Description of QM program in a written quality plan, with a clear
indication of responsibilities and responsible parties
 Inclusion and involvement of key stakeholders in your quality
program
 Designated leaders for quality improvement and accountability
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National Quality Center (NQC)
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
• “assess the extent to which HIV health services are
consistent with the most recent Public Health Service
(PHS) guidelines…” which includes:
 Development and/or adaptation of quality indicators for
key clinical and service categories
 Routine performance measurement of key care aspects
 Sharing of performance data with program staff
 Use of data to improve the organization’s performance
on key services
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National Quality Center (NQC)
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
• “develop strategies for ensuring that such services are
consistent with the guidelines for improvement in
access to and quality of HIV service…” that include:
 Linking performance data results to quality improvement
activities
 Establishment of quality improvement teams with cross-
functional representation
 Integration of changes into routine program activities
61
National Quality Center (NQC)
Key Characteristics of a Quality Management
Program
Patient-centeredness is a fundamental focus of quality care and
undergirds the 5 characteristics that follow.
1. A systematic process with identified leadership,
accountability, and dedicated resources available to the
program
2. Use data and measurable outcomes to determine
progress toward relevant, evidenced-based benchmarks
3. Focus on linkages, efficiencies and provider, and client
expectation in addressing outcome improvement
62
National Quality Center (NQC)
Key Characteristics of a Quality Management
Program (cont.)
4. A continuous process that is adaptive to change and that
fits within the framework of other programmatic quality
assurance and quality improvement activities
5. Ensure that data collected are fed back into the quality
improvement process to assure that goals are
accomplished and that they are concurrent with improved
outcomes
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National Quality Center (NQC)
Quality Improvement Resources:
Websites, Publications, Technical Assistance
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National Quality Center (NQC)
Quality Improvement Websites
NationalQualityCenter.org
•
•
•
•
•
•
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HIV measures
Change ideas
Best practices
Tools/resources
Literature
FAQ
National Quality Center (NQC)
Quality Improvement Websites
www.HIVQUAL.org
•
•
•
•
•
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HIV QI publications
Measures
HIVQUAL Project
Clinical guidelines
Recent news and
events
National Quality Center (NQC)
Websites for Quality Improvement
hab.hrsa.gov
• HRSA QI expectations
• QI Tools
• TA Resources
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National Quality Center (NQC)
QI Learning Resources
Starting to Learn about Quality
Improvement
Measuring Quality of HIV Care
Measurement
Setting up a QM Infrastructure
Writing a Quality Management Plan
Conducting Quality Improvement
Activities
68
National Quality Center (NQC)
QI Teaching Resources
Teaching Quality Improvement
Fundamentals
Teaching Performance
Measurement
Teaching QM Infrastructure
Teaching Quality Improvement
Activities
Teaching Patients on Quality
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National Quality Center (NQC)
Consumer Involvement Training Materials
Soliciting Patient Feedback
Empowering Patients to Partner with
their Health Care Providers
Maintaining a Patient Health Record
Best Practices for Consumer
Involvement
Teaching Providers about Patient
Self-Management
70
National Quality Center (NQC)
Quality Academy (Online Training Course)
• Online quality improvement
training course – at no cost
available 24/7 (also
available on CD-Rom)
• Interactivity through test
questions and online
exercises
• 20 QI topics from beginner
(e.g., QI 101, PDSA) to
advanced levels (e.g.,
dealing with resistance)
NationalQualityCenter.org/QualityAcademy
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National Quality Center (NQC)
Quality Improvement Publications
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National Quality Center (NQC)
Quality Improvement Publications
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National Quality Center (NQC)
Quality Improvement Publications
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National Quality Center (NQC)
Quality Improvement Publications
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National Quality Center (NQC)
Quality Improvement Publications
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Quality Improvement Publications
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National Quality Center (NQC)
Quality Improvement Publications
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National Quality Center (NQC)
HIVQUAL Software and QM Plan Checklist
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National Quality Center (NQC)
HIVQUAL Indicators –
Adult and Adolescent
•
ARV THERAPY MANAGEMENT
•
HIV MONITORING (CD4 and VL
testing)
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•
HIV SPECIALIST CARE
•
ANTIRETROVIRAL THERAPY
MEDICATION
•
TUBERCULOSIS SCREENING
(PPD)
•
SYPHILIS SCREENING
•
HEPATITIS C SCREENING
•
VACCINATION
•
TREATMENT EDUCATION
•
SUBSTANCE USE
•
ADHERENCE TO ARV THERAPY
•
MENTAL HEALTH CARE
•
PCP PROPHYLAXIS
•
DENTAL CARE
•
MAC PROPHYLAXIS
•
•
OPHTHALMOLOGICAL CARE
GYNECOLOGY EXAMS
•
LIPID SCREENING
•
BASIC PATIENT EDUCATION
National Quality Center (NQC)
HIVQUAL Indicators – Pediatric
•
ARV THERAPY MANAGEMENT
• PCP PROPHYLAXIS
•
HIV MONITORING (CD4 and VL
• MAC PROPHYLAXIS
testing)
•
HIV PEDIATRIC SPECIALIST
CARE
•
ANTIRETROVIRAL THERAPY
MEDICATION ADHERENCE
• ROUTINE VACCINATIONS
• NEURODEVELOPMENTAL
ASSESSMENTS
• MULTIDISCIPLINARY CARE
PLAN
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National Quality Center (NQC)
HIVQUAL Indicators –
Case Management
• Case Management
 Complete psychosocial assessment
 Patient Knowledge Screening
 Treatment Adherence Assessment
 Service Care Plan & Coordination of Care
 Access and Continuity
 Self-Management: Client Participation in Care Planning
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National Quality Center (NQC)
Technical Assistance Resources
National Quality Center (NQC)
NYSDOH AIDS Institute
90 Church Street—13th Floor
New York, NY 10007-2919
888-NQC-QI-TA
[email protected]
83
National Quality Center (NQC)
Technical Assistance Resources
National HIVQUAL Project
NYSDOH AIDS Institute
90 Church Street—13th Floor
New York, NY 10007-2919
212 417 4536
[email protected]
84
National Quality Center (NQC)
Evaluation
Funded by HRSA
HIV/AIDS Bureau
How do you rate this workshop?
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Very Good
Good
Okay
So, So
Not Very Good
10
National Quality Center (NQC)
The workshop kept me interested
and engaged?
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87
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
National Quality Center (NQC)
The workshop gave me practical strategies
and solutions to use at my HIV program.
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88
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3.
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5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
National Quality Center (NQC)
The workshop topic was relevant to me and
my HIV program.
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0%
89
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2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
National Quality Center (NQC)
The presenters at this workshop were experts
and answered questions effectively.
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90
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5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
National Quality Center (NQC)
The workshop had the right balance of
lecture and interactive activities.
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91
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
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I liked the little remotes….
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92
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10
National Quality Center (NQC)
Thank You :-)
Funded by HRSA
HIV/AIDS Bureau
National Quality Center (NQC)
212.417.4730
NationalQualityCenter.org
[email protected]
Funded by HRSA
HIV/AIDS Bureau