GOAL:To evaluate how the HIV program applies robust process improvement methodology* to achieve program goals and maintain high levels of performance over long periods of time.
The Quality Improvement Initiatives section examines how leadership and workforce use these methods and tools to conduct improvement initiatives with emphasis on identification of the exact causes of problems and designing effective solutions, determining program specific best practices, and sustaining improvement over long periods of time. In high reliability organizations robust process improvement methodology is routinely utilized for all identified problems and improvement opportunities to assure consistency in approach by all staff members.
*Robust process improvement includes reliably measuring the magnitude of a problem, identifying the root causes of the problem, measuring the importance of each cause, finding solutions for the most important causes, proving the effectiveness of those solutions, and deploying programs to ensure sustained improvements over time.
D.1. To what extent does the HIV program identify and conduct quality improvement initiatives using robust process improvement methodology to assure high levels of performance over long periods of time? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
QI initiatives:
Formal quality improvement projects have not yet been initiated in the program.
Planning and initiation
1
QI initiatives:
No assessment of organizational performance or system level analysis of data performed; are not team-based and do not use specific tools or methodology.
Focus on individual cases only.
Reviews are primarily used for inspection.
Beginning implementation
2
QI initiatives:
Are prioritized by the quality committee based on program goals, objectives and analysis of performance measurement data.
Involve team leaders and team members who are assigned by the quality committee or other leadership.
Begin to use specific tools or methodology to understand causes and make effective changes.
Implementation
3
QI initiatives:
Are ongoing based on analysis of performance data and other program information, including external reviews and assessments.
Focus on processes of care in which QI methodology is routinely utilized.
Are regularly documented and provided to Quality Improvement Committee.
Involve staff on QI teams. Cross departmental/cross functional teams are developed depending on specific project needs.
Progress toward systematic approach to quality
4
QI initiatives:
Reflect input from staff through a transparent process.
Routinely and consistently reinforce and promote a culture of quality improvement throughout the program through shared accountability and responsibility of identified improvement priorities.
Are supported with appropriate resources to achieve effective and sustainable results.
Involve support of data collection with results routinely reported to QI project teams.
Full systematic approach to quality management in place
5
QI initiatives:
Are ongoing in every service category.
Correspond with a structured process for prioritization based on analysis of performance data and other factors.
Are implemented by project teams. Further, physicians and staff can identify an improvement opportunity at any point in time and suggest a QI team be initiated.
Consistently and routinely utilize robust process improvement and multidisciplinary teams to identify actual causes of variation and apply effective sustainable solutions.
Consistently and routinely utilize robust process improvement and multidisciplinary teams to identify actual causes of variation and apply effective sustainable solutions..
Are regularly communicated to the Quality Committee, staff and patients.
Routinely involve consumers on QI project teams.
Are presented in storyboard context or other formats and reported to larger organization and/or placed in public areas for staff and patients (if relevant).
Involve recognition of successful teamwork by senior leadership.
Are supported by development of sustainability plans.