Measurement, Analysis, and Use of Data to Improve Program Performance
GOAL:To assess how the HIV program uses data and information to identify opportunities for improvement, to develop measures to evaluate the success of change initiatives, to align initiatives, to monitor program status, and to ensure that accurate, timely data and information are available to stakeholders throughout the organization to drive effective decisions.
The Measurement, Analysis, and Use of Data section assesses how the program selects, gathers, analyzes, and uses data to improve performance. This includes how leaders conduct performance reviews to ensure that actions are taken, when appropriate, to achieve program goals.
C.1. To what extent does the HIV program routinely measure performance and use data for improvement? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
Performance measures:
Performance measures have not been identified.
Planning and initiation
1
Performance measures:
Have been identified to evaluate some components of the program but do not cover all significant aspects of service delivery.
Are defined and used by personnel at some but not all units or sites.
Performance data:
Collection is planned pending initiation.
Beginning implementation
2
Performance measures:
Are externally defined and used by personnel at all applicable site.
Performance data:
Validation, analysis, and interpretation of results on measures are in early stages of development and use.
Results are occasionally shared with staff and patients.
Implementation
3
Performance measures:
Are externally defined or required (e.g., HAB, HIVQUAL), with the intent to meet external regulatory requirements and the needs of stakeholders, including patients.
Are defined and consistently used by personnel at all applicable sites.
Performance data:
Are tracked, analyzed, and reviewed with the frequency required to identify areas in need of improvement. A structured review process is used regularly by the leadership to identify and prioritize improvement needs and to initiate action plans to ensure that goals are achieved.
Are collected by staff with working knowledge of indicator definitions and their application.
Results and associated measures are routinely shared with staff and their input is elicited to make improvements.
Progress toward systematic approach to quality
4
Performance measures:
Are externally defined or required (e.g., HAB, HIVQUAL) and tied to annual organizational goals, with the intent to meet external regulatory requirements and the needs of stakeholders and patients, and goals of alignment with current evidence in the diagnosis and treatment of HIV.
Reflect priorities of clinic staff and patients, in consideration of local issues.
Performance data:
Results and associated measures are frequently shared with staff to elicit their input and engage them in improvement processes aligned with organizational goals.
Full systematic approach to quality management in place
5
Performance measures:
Are selected using organizational annual goals, with the intent to meet external regulatory requirements as well as the needs of stakeholders and patients, and the goal of alignment with current evidence in the diagnosis and treatment of HIV.
Reflect priorities of clinic staff and patients, in consideration of local issues.
Are defined for each program component and actively used to drive improvement activities.
Are evaluated regularly to ensure that the program is able to respond effectively and quickly to internal and external changes.
Performance data:
Are visible or easily accessible to ensure data reporting transparency throughout the clinic.
Are arrayed in formats that enable accurate interpretation, such as run charts and/or control charts.
Results and associated measures are systematically shared with all stakeholders, including staff, patients, and board members, to elicit their input and engage them in improvement processes aligned with organizational goals.