GOAL:To assess how the HIV program generates, uses organizational HIV treatment cascades to identify opportunities for improvement, and develop data-driven improvement plans that are aligned with the goals of the New York State Ending the Epidemic Initiative.
The Ending the Epidemic section assesses how the program selects, gathers, analyzes and uses data based on the HIV treatment cascades to improve performance. This includes how cascade data are collected and used by leaders, staff and the quality program to improve outcomes along the cascade throughout the entire healthcare agency and to achieve program goals.
H.1. To what extent does the HIV program routinely generate and use organizational cascades to drive improvement and address gaps in care? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
Facility:
Does not report required rates of patients newly diagnosed, newly diagnosed patients linked to care, newly diagnosed patients on ARV or who are virally suppressed.
Does not report on the # of open patients with HIV who were engaged at the organization for reasons other than HIV care.
Planning and initiation
1
Facility:
Reports required rates of patients newly diagnosed, newly diagnosed patients linked to care, newly diagnosed patients on ARV and who are virally suppressed.
Reports on the # of open patients with HIV who were engaged at the organization for reasons other than HIV care.
Beginning implementation
2
Facility:
Constructs an annual HIV treatment cascade that visually displays data, showing the interconnection between rates of patients newly diagnosed, newly diagnosed patients linked to care, newly diagnosed patients on ARV, and who are virally suppressed.
Constructs an HIV treatment cascade for established patients that identifies gaps in engagement in care, antiretroviral therapy and viral suppression.
Implementation
3
Facility:
Presents the methodology underlying the construction of the HIV treatment cascades that includes sources of data, limitations, how data were extracted, and how exclusions were determined.
Analyzes the organizational cascades to understand why patients do not meet expected outcomes.
Develops a quality improvement plan that reflects the findings and gaps identified by the organizational cascades.
Tracks the outcomes of interventions specified in the improvement plan.
Involves community service agencies, as necessary, in process analysis and development of improvement plans to address linkage, engagement, re-engagement, and viral suppression.
Makes its cascade visible to internal stakeholders at all levels, including quality management committees, advisory boards, and patient or client groups.
Progress toward systematic approach to quality
4
Facility:
Measures whether those PLWH who access services with any unit of the facility (including, but not limited to emergency department and supportive services) have an identified HIV medical provider.
Measures whether those PLWH who access services with any unit of the facility (including, but not limited to emergency department, inpatient unit and supportive services) have been seen by an HIV medical provider in the past 6 months, with documentation of findings.
Reaches out to its local health department, the State or other sources, including RHIOs if possible, to determine if each patient has been engaged in care elsewhere.
Stratifies cascade data to identify potential disparities in care provided to subpopulations.
Full systematic approach to quality management in place
5
Facility:
Produces complete HIV treatment cascades at least every six months, that include facility-wide testing and linkage rates within the institution, including, but not limited to emergency departments, inpatient units and appropriate ambulatory care clinics.
Reports on progress of previous improvement plans based on cascade data.
Demonstrates how the findings from the treatment cascades and improvement plans have been incorporated into the organizational quality management plan.
Implements improvement strategies to reduce disparities in care provided to subpopulations.