HIVQUAL Workbook Guide for Quality Improvement in HIV Care New York State Department of Health AIDS Institute Health Resources and Services Administration HIV/AIDS Bureau “Untitled” - painting by Frank Holliday, HIV-positive artist HIVQUAL Workbook Guide for Quality Improvement in HIV Care New York State Department of Health AIDS Institute Health Resources and Services Administration HIV/AIDS Bureau Developed by the New York Department of Health AIDS Institute The National HIVQUAL Project For the U.S. Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau September 2006 This publication was supported by grant number 231030010FR from the HIV/AIDS Bureau, Health Resources and Services Administration. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration. 2 New York State Department of Health Office of the Medical Director AIDS Institute HIV Quality of Care Program Guthrie Birkhead, M.D., M.P.H. Bruce Agins, M.D., M.P.H. Director Medical Director Humberto Cruz, M.S. Clemens Steinböck, M.B.A. Executive Deputy Director Director of Quality Initiatives Barbara Devore, M.P.A. Franklin Laufer, Ph.D. Executive Deputy Director Director for Performance Measurement Bruce Agins, M.D., M.P.H. Todd Mohrmann, M.A. Medical Director Manager, HIV Guidelines Program NYSDOH AI HIVQUAL Workbook September 2006 3 The HIVQUAL Project Bruce Agins, MD, MPH Onelia Crespo, M.D. HIVQUAL Project Director QI Consultant Clemens Steinböck, M.B.A. Lori DeLorenzo, M.S.N, R.N. HIVQUAL Specialist QI Consultant Lily Jiang Jeffrey A. Menzer, R.N., A.C.R.N. HIVQUAL Project Data Manager QI Consultant Chris Wells Margaret Palumbo, M.P.H. HIVQUAL Data Analyst QI Consultant Nanette Brey-Magnani, Ed.D. Barbara Rosa, R.N.-C., M.S. QI Consultant QI Consultant Amelia Broussard, Ph.D., R.N., M.P.H. Dan Sendzik QI Consultant QI Consultant Johanna Buck, M.A., R.N. Nancy Showers, D.S.W. QI Consultant QI Consultant Kathleen Clanon, M.D. Saneese Stephen, R.P.A.-C., M.P.A. QI Consultant QI Consultant NYSDOH AI HIVQUAL Workbook September 2006 4 Table of Contents Index.. .7 Introduction . .13 Workbook Use . .15 National HIVQUAL Project . .17 Overview of the HIVQUAL Model . .21 Resources . .26 Program Cycle - HIVQUAL Model Step I: Develop and Plan a Quality Management Program . 28 Identify Leaders and Key Stakeholders . 30 Form a Quality Management Committee . .32 Develop a HIV Quality Management Management Plan . 38 Strategize Implementation of the Quality Plan . .49 Step II: Facilitate Implementation of HIV Quality Program . .55 Establish Performance Measurement Systems . .57 Review Performance Measurement Data. 60 Establish Improvement Project Teams. .61 Support Quality Improvement Activities. .63 Step III: Evaluate HIV Quality Management Program. .69 Evaluate HIV Quality Management Program Eff ectiveness . .71 Evaluate Project Team Performance . .75 Learn from and Respond to Past Performance . 77 Strategize to Sustain the HIV Quality Program . .78 NYSDOH AI HIVQUAL Workbook September 2006 5 Project Cycle - HIVQUAL Model Step 1: Review, Collect and Analyze Project Data . .82 Review and Collect Project Data . .84 Analyze and Share Results . .90 Step 2: Develop a Project Team . .93 Establish Project Team Dynamics . .95 Write an Improvement Project Memo . .98 Step 3: Investigate the Process . 103 Understand the Process . 106 Identify Underlying Causes . 110 Step 4: Plan and Test Changes . 116 Conduct Plan-Do-Study-Act (PDSA) Cycles . 118 Plan for Pilot Tests . .120 Conduct Pilot Tests . .125 Step 5: Evaluate Results with Key Stakeholders . .127 Summarize Improvement Project Results . 129 Evaluate Results with HIV Quality Committee . 132 Step 6: Systematize Changes . .134 Sustain Improvements . .136 Assess Team Eff ectiveness . 140 Additional Resources Sampling and Data Collection . 142 Construct a population Sample . 143 Design a Data Collection Tool . 147 Assign and Train Abstractors . 151 Validate Results . 156 NYSDOH AI HIVQUAL Workbook September 2006 7 Index A L Assessment tool, quality program . 72 Leaders and key stakeholders . 30 B O Baseline data, analysis . 84 Organizational assessment tool . 72 Brainstorming . 110 P C Pareto chart . 115 Cause-and-eff ect diagram . 110, 113 PDSA cycle . 118 Cause analysis . 110 Performance data, collection . 86 Performance measurement system . 57 D Pilot test, evaluation . 125 Data abstractors . 86, 151 Pilot test, implementation . ..