Purpose

This assessment, which is included in an appendix in the booklet shown at the left, identifies all of the important elements associated with a sustainable quality management program.

Purpose of the Organizational Assessment

Sustained improvement activities require attention to the organizational Quality Management Program (QMP), in which structures, processes, and functions support measurement and improvement activities. Development, implementation, and spread of sustainable quality improvement (QI) throughout an HIV program require an organizational commitment to quality management. Organizational infrastructure is fundamental to QI success and involves a receptive organization, sustained leadership, staff training and support, time for teams to meet, and data systems for tracking outcomes. This structure supports quality initiatives that apply robust process improvement, including reliable measurement, root cause analysis, and finding solutions for the most important causes identified.

This assessment identifies all of the important elements associated with a sustainable QMP. Scores from 0–5 are defined to identify gaps in the QMP and to set program priorities for improvement. The scoring structure measures program performance in specific domains along the spectrum of improvement implementation. When assigning a score of 0–5 for individual components, the whole number that most accurately reflects organizational achievement in that area should be selected. If there is any uncertainty in assessing whether performance is closer to the statement in the next higher or next lower range, choose the lower score. Scoring is designed so that all items in a score must be satisfied to reach any one score for a component. Applied annually, this assessment will help a program evaluate its progress and guide the development of goals and objectives.

The OA is implemented in two ways: 1) by an expert QI consultant or 2) as a self-evaluation. The results are ideally used to develop a workplan for each element with specific action steps and timelines guiding the planning process to focus on priorities, setting direction, and ensuring that resources are allocated for the QMP. Whether performed by a QI consultant or applied as a self-evaluation, key leadership and staff should be involved in the assessment process to ensure that all key stakeholders have an opportunity to provide important information related to the scoring.

Results of the OA should be communicated to internal key stakeholders, leadership, and staff. Engagement of program leadership and staff is critical to ensure buy-in across the program and is essential for translating results into improvement practice.

To request an expert QI consultant to implement your OA, contact Dan Belanger, Director of the HIV Quality of Care Program, at Daniel.belanger@health.ny.gov or by phone at (212) 417-5131.