NYS HIV Quality of Care Program Standards


Infrastructure of the HIV Quality Management Program


The HIV quality management program is actively supported and formally guided by clinical leaders for medical programs or by senior program leaders for nonmedical service programs, who provide institutional commitment and allocate appropriate resources to ensure sustainable implementation of improvement activities. The HIV quality management program is effectively linked with the organization-wide quality management program, as evidenced by the routine reporting of improvement efforts and performance measurement data.


HIV Program Staff

Program staff are aware of the quality management infrastructure, understand their roles in improvement activities, and actively participate in agency-wide quality management program activities.


HIV Quality Management Committee

The HIV quality management committee is accountable for HIV-specific improvement activities, development of annual quality improvement goals, prioritization of key quality indicators for review, routine evaluation of the HIV quality management program, and sharing of HIV performance data with staff and stakeholders, including consumers. The committee membership includes staff from all key medical and non-medical services. Consumer representatives are included who provide input to ensure that services effectively meet or exceed patient needs and expectations. The committee meets at least once every other month.


Quality Management Plan

Each HIV quality management program has a written quality management plan that is reviewed and updated annually by the HIV quality management committee. The plan is shared with staff and consumers to gather input and to promote involvement in the quality management program and its activities. The plan includes the following elements:

  • Quality statement describing the overall mission of the HIV quality management program and its integration within the quality management infrastructure of the wider organization;
  • Staffing plan describing roles and responsibilities pertaining to the quality management program including the quality committee, its membership, and leadership;.
  • Performance measurement activities describing indicators and data collection methodologies;
  • Annual improvement goals based on identified gaps in specified performance data, as well as internal program priorities and statewide public health objectives;
  • Processes for training and engagement of staff, consumers, and stakeholders; and
  • Procedure(s) for routine evaluation of the quality management program.


The quality management plan includes a formal workplan that identifies implementation responsibilities and a timetable for their completion. The workplan is reviewed routinely at quality management committee meetings and is in the formal evaluation of the HIV program to monitor whether it is being implemented as planned and whether goals are achieved.