Organizational Assessments

Quality Program Evaluation

GOAL: To assess how the program evaluates the extent to which it is meeting the identified program goals related to quality improvement planning, priorities, and implementation.

Quality program evaluation can occur at any point during the cycle of quality activities but should occur annually at a minimum. The process of evaluation should be linked closely to the quality plan goals: to assess what worked and what did not, to determine ongoing improvement needs and to facilitate planning for the upcoming year. The evaluation examines the methodology, infrastructure and processes, and assesses whether these led to expected improvements and desired outcomes. At a minimum, the evaluation should assess access to data to drive improvements, success of QI project teams; and effectiveness of quality structure. Where appropriate, external evaluations and assessments should be utilized in partnership with the internal evaluation. The evaluation is most effectively performed by program leadership and the program’s quality committee, optimally with some degree of consumer involvement.

F.1. Is a process in place to evaluate the HIV program’s infrastructure, activities, processes, and systems to ensure attainment of quality goals, objectives, and outcomes? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0
Quality program evaluation:
  • No formal process is established to evaluate the quality program.
Planning and initiation 1
Quality program evaluation:
  • To assess program processes and systems is exclusively external.
Beginning implementation 2
Quality program evaluation:
  • Is part of a formal process and is integrated into annual quality management plan development.
Implementation 3
Quality program evaluation:
  • Occurs annually, conducted by the quality committee, and includes QM plan and workplan updates and revisions.
  • Involves annual (at minimum) revision of quality goals and objectives to reflect current improvement needs.
  • Results are used to plan for future quality efforts.
  • Includes a summary of improvements and performance measurement trends to document and assess the success of QI projects.
  • Results, noted above, are shared with consumers and other key stakeholders.
Progress toward systematic approach to quality 4
Quality program evaluation:
  • Findings are integrated into the annual quality plan and used to develop and revise program priorities.
  • Is reviewed during quality committee meetings to assess progress toward planning goals and objectives.
  • Includes review of performance data, which is used to inform decisions about potential changes to measures.
  • Is used to determine new performance measures based on new priorities.
  • Includes analysis of QI interventions to inform changes in program policies and procedures to support sustainability.
Full systematic approach to quality management in place 5
Quality program evaluation:
  • Findings are integrated into routine program activities as part of a systematic process for assessing quality activities, outcomes, and progress toward goals; data and information are provided regularly to the quality committee.
  • Is used by the quality committee to regularly assess the success of QI project work, successful interventions, and other markers of improved care.
  • Includes data reflecting improvement initiatives and is presented to ensure comprehensive analysis of all quality activities.
  • Uses a detailed assessment process. The results of this assessment are utilized to revise and update the annual quality plan, adjust the HIV program priorities, and identify gaps in the program.
  • Includes an analysis of progress toward goals, objectives, QI program successes, and accomplishments.
  • Describes performance measurement trends, which are used to inform future quality efforts.
  • Communicates evidence that QI efforts informed through this process resulted in measurable improvement.