AMC Albany AIDS Clinic Process Improvement Management Plan 2006

The Albany Medical Center Division of HIV Medicine (DHIVM), Albany site serves over 1200 patients annually. We offer comprehensive HIV services including access to clinical research, primary care, case management, adherence, dental, mental health, nutrition, and related services.

Mission Statement. The mission of the Albany Medical Center Division of HIV Medicine Albany site Process Improvement Team is to ensure the highest quality of care for the patients receiving outpatient clinical services at the Albany Medical Center (AMC) Division of HIV Medicine (DHIVM), Albany site. The focus is on changes that improve outcomes on clinical standards.

The Process Improvement Team has the responsibility to serve as a catalyst for continuous improvement in patient care, educate AMC DHIVM staff on basic principles of process improvement, and serve as a resource for staff initiating change.

Process Improvement Infrastructure. The “core” PI team, comprised of the operations manager, process improvement coordinator, and clinical director, is responsible for guiding the direction of PI, maintaining focus on goals, and removing barriers whenever possible. This team meets 1-2 times per month. The DHIVM medical director and/or program administrator are consulted as needed.

The multidisciplinary PI “home team” is comprised of the core team as well as managers from the following areas: client services, clerical, information systems, nursing, and primary care providers. This team meets monthly. The DHIVM medical director and program administrator attend meetings when feasible and are consulted as needed. Ad-hoc workgroups are sometimes created to prevent delays in the process.

The program administrator, medical director, and process improvement coordinator also participate in the Albany Medical Center Hospital’s AIDS quality improvement team (QIT) meetings (held monthly).

Decisions within the PI structure are made using a modified consensus approach: 1. If consensus for a decision cannot be reached within 3 agenda discussions, the decision responsibility is forwarded to the core team. 2. If consensus is not reached within the core team, the AIDS program medical director has the ultimate decision-making authority.

The ultimate responsibility for leadership of process improvement lies with the AMC Division of HIV Medicine Medical Director.

2006 PI Management Plan Page 1 of 2 Annual Quality Goals. PI efforts this year will be focused on redesign of systems and resources allocation to improve our measures of annual comprehensive exams (ACE), patient retention, annual PPD reading rates, and annual Pap tests (women only). Specific goals include: . 60% of active patients (at least one medical visit in last year) with ACE . 90% of active patients with visit in the previous 4 months . 60% of active patients with a PPD reading in the previous 12 months . 70% of active patients with a secondary prevention intervention in the previous 12 months . 80% of active female patients with a Pap test in the previous 12 months.

In addition, we will develop tools to improve patient care in addressing dual- diagnosis issues. These include (but are not limited to): . Developing a Mental Health screening tool that encompasses the 7 HIVQUAL components of the Mental Health screen. Testing of this tool will begin in the first quarter of 2006. . Developing a flow sheet that incorporates diabetes-specific standards of care.

Staff Involvement. Staff is informed of the DHIVM PI initiatives and progress toward goals at monthly staff meetings. PI meeting minutes are available on the DHIVM share drive. The PI coordinator meets with providers 3-4 times per year to receive and provide feedback on current and future PI activities. In addition, the medical director facilitates focused PI intervention discussion at 1-2 full staff meetings per year. The process improvement coordinator serves as a resource to all staff interested in initiating change.

Consumer Involvement. The PI Coordinator provides updates on PI goals at all Community Advisory Board (CAB) meetings. CAB members provide feedback and suggestions to help achieve PI goals.

Evaluation. PI performance is evaluated by: . quarterly review of progress toward goals . annual review of goal achievement . annual review of effectiveness of PI structure.

Addendum 4/24/06 Diabetes flow sheet options presented to providers. Providers agreed on a single flowsheet encompassing all diabetes standards. 4/24/06 New project-“new patient checklist” to be developed to ensure baseline information /assessments are completed on new patients. 5/9/06 Mental Health Screening tool revised to encompass new domestic violence and post traumatic stress disorder components. Cognitive components not included in screening tool. Components of mental health indicator have been reviewed with providers. Testing of screening tool began 5/9/06.

2006 PI Management Plan Page 2 of 2