GOAL:To assess the HIV program infrastructure to support a systematic process with identified leadership, accountability, and dedicated resources.
Three components form the backbone of a strong, sustainable quality program: Leadership, Quality Planning, and a Quality Committee.
1. Leadership: Senior leadership personnel are defined by each organization since titles and roles vary among organizations. Clinical HIV programs should include a clinical leader (medical director, senior nurse) and an administrative leader (program coordinator, clinic manager, administrative director). Larger programs may include additional leadership positions. There may be other informal leaders in the organization who support quality activities, but these are not included in this section.
Leaders establish a unity of purpose and direction for the organization and work to engage all personnel, consumers, and external stakeholders in meeting organizational goals and objectives. This includes providing motivation that promotes shared responsibility and accountability with a focus on teamwork and individual performance. HIV program leaders should prioritize quality goals and improvement projects for the year and should establish accountability for performance at all organizational levels. The benefits of strong leadership include the clear communication of goals and objectives, wherein evaluation, alignment, and implementation of activities are fully integrated.
Evidence of leadership support and engagement includes the establishment of clear goals and objectives, the communication of program/organizational vision, the creation and sustainment of shared values, and the provision of resources for implementation.
2. Quality Committee: A quality committee drives implementation of the quality plan and provides high-level comprehensive oversight of the quality program. This involves reviewing performance measures, developing workplans, chartering project teams, and overseeing progress. Teams should be multidisciplinary and include a consumer when feasible. Consumer representation on the committee should be part of a formal engagement process wherein consumer feedback is solicited and integrated into the decision-making process. The committee should have regularly scheduled meetings, meeting notes to be distributed throughout the program, and a committee chair or chairs.
3. Quality Plan: Quality improvement planning occurs with initial program implementation and annually thereafter. A quality management plan documents programmatic structure and annual quality team goals. The quality plan should serve as a road map to guide improvement efforts and should include a corresponding workplan to track activities, monitor progress, and signify achievement of milestones.
A.1. To what extent does senior leadership create an environment that supports a focus on improving the quality of HIV care?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
Leaders are:
Senior leaders are not visibly engaged in the quality of care program.
Planning and initiation
1
Leaders are:
Not fully involved in improvement efforts, quality meetings, supporting provision of resources for QI activities.
Primarily focused on external requirements and supporting compliance with regulations.
Inconsistent in use of data to identify opportunities for improvement.
Beginning implementation
2
Leaders are:
Not engaged optimally.
Engaged in quality of care with focus on use of data to identify opportunities for improvement.
Somewhat involved in improvement efforts.
Somewhat involved in quality meetings.
Supporting some resources for QI activities.
Implementation
3
Leaders are:
Providing routine leadership to support the quality management program.
Providing routine and consistent allocation of staff or staff time for QI (depending on facility size).
Actively engaged in QI planning and evaluation.
Actively managing/leading quality meetings.
Clearly communicating quality goals and objectives to all staff.
Recognizing and supporting staff involved in QI.
Routinely reviewing performance measures and patient outcomes to inform program priorities and data use for improvement.
Attentive to national health care trends/priorities that pertain to the program.
Progress toward systematic approach to quality
4
Leaders are:
Supporting development of a culture of QI across the program, including provision of resources for staff participation in QI learning opportunities, seminars, professional conferences, QI story boards for distribution and drafting of scholarship, etc.
Supporting prioritization of quality goals based on data, and critical areas of care are addressed in coordination with broader strategic goals for HIV care.
Promoting patient-centered care and consumer involvement through the Quality Management Program.
Routinely engaged in QI planning and evaluation.
Routinely providing input and feedback to QI teams.
Full systematic approach to quality management in place
5
Leaders are:
Actively engaged in the implementation and shaping of a culture of QI across the program, including provision of resources for staff participation in QI learning opportunities, seminars, professional conferences, QI story boards for distribution and drafting of scholarship, etc.
Encouraging open communication through routine team meetings and dedicated time for staff feedback.
Routinely and consistently engaged in QI planning and evaluation.
Routinely and consistently providing input and feedback to QI teams.
Encouraging staff innovation through QI awards or incentives.
Directly linking QI activities back to institutional strategic plans and initiatives.
A.2. To what extent does the HIV program have an effective quality committee to oversee, guide, assess, and improve the quality of HIV services?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
A Quality Committee has not yet been developed or formalized or is not currently meeting regularly to provide effective oversight for the quality program.
Planning and initiation
1
The quality committee:
May review data triggered by an event/problem or generated by donor or regulatory urging.
Has minimally integrated quality activities into other existing meetings.
Beginning implementation
2
The quality committee:
Has plans to hold regular meetings, but meetings may not occur regularly and/or do not focus on performance data.
Has been formalized, representing most institutional disciplines.
Has identified roles and responsibilities for participating individuals.
Implementation
3
The quality committee:
Is formally established and led by a program director, medical director or senior clinician.
Has implemented a structured process to review data for improvement.
Has defined roles and responsibilities as codified in the quality plan.
Reviews performance data regularly, including staff and consumer satisfaction, if available.
Discusses QI progress and redirects teams as appropriate.
Progress toward systematic approach to quality
4
The quality committee:
Is formally established and led by a program director, medical director or senior clinician specifically tasked with active oversight of the work of the quality program with established annual meeting dates.
Represents all disciplines.
Has established a performance review process to regularly evaluate clinical measures and respond to results as appropriate, including staff and consumer satisfaction.
Communicates with non-members through distribution of minutes and discussion in regular staff meetings.
Actively utilizes a workplan to closely monitor progress of quality activities and team projects.
Provides progress reports to the organization-wide quality program.
Full systematic approach to quality management in place
5
The quality committee:
Is a formal entity led by a senior clinician or administrator and, where appropriate, is linked to organizational Quality Committees through common members.
Has established a systematic performance review process, including clinical, consumer satisfaction and operational measures to identify annual goals.
Is responsive to changes in treatment guidelines and external/national priorities (NAHS, HAB, CMS), which are considered in development of indicators and choosing improvement initiatives.
Has fully engaged senior leadership and they lead discussions during committee meetings.
Effectively communicates activities, annual goals performance results and progress on improvement initiatives to all stakeholders, including staff, consumers and board members.
A.3. To what degree does the HIV program have a comprehensive quality plan that is actively utilized to oversee quality improvement activities?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
A quality plan, including elements necessary to guide the administration of a quality program, has not been developed.
Planning and initiation
1
The quality plan:
Is written with some of the essential components necessary to direct an effective quality program (see level 3).
May be written for the parent organization or for the network but plans specific to the HIV program or for the network have not yet been developed.
Beginning implementation
2
The quality plan:
Is written for the HIV program and contains some of the essential components (see level 3).
Is under review for approval (if required by organization) by senior leadership and includes steps for implementation.
Implementation
3
The quality plan:
Reflects an effective HIV-specific quality program with all the essential QI components including:
annual goals and objectives,
roles, responsibilities
logistics,
performance measurement and review processes,
QI methodology
communication strategy,
consumer involvement,
program evaluation procedure
Includes an annual workplan/timeline outlining key activities of the quality program and improvement initiatives.
Progress toward systematic approach to quality
4
The quality plan:
Has been implemented and is used regularly by the quality committee to direct the quality program.
Includes annual goals identified on the basis of internal performance measures and external requirements through engaged of the quality committee and staff.
Workplan is modified as needed to achieve annual goals.
Is routinely communicated to stakeholders, including staff, consumers, board members and the parent organizations, if appropriate.
Is evaluated annually by the quality committee to ensure that the needs of all stakeholders are met and that changes in the healthcare and regulatory environment are assessed to ensure that the program meets the changing needs of the HIV patient.
Full systematic approach to quality management in place
5
The quality plan:
Is written, implemented and regularly utilized by the quality committee to direct the quality program and includes all necessary components (see level 3).
Includes regularly updated annual goals that were identified by the quality committee using data on internal performance measures and external requirements through engagement of the quality committee and staff.
Includes a workplan/timeline outlining key activities in place and is routinely and consistently used to track progress on performance measures and improvement initiatives and modified as needed to achieve annual goals.
Is aligned with that of the parent organization and/or all network sites, as appropriate.