Workforce Engagement in the HIV Quality of Care Program
GOAL:To assess awareness, interest, and engagement of staff in quality improvement activities.
Staff engagement in quality activities at all organizational levels is central to QI success. This includes development and promotion of staff knowledge around organizational systems and processes to build sustainable quality management programs, such as internal management processes, operational barriers, patient interaction, and successful strategies and barriers to QI implementation.
Ongoing training and retraining in QI methodology and practical skills reinforces knowledge and the building of workforce expertise around QI. Training and retraining of staff can be accomplished through formal sessions provided internally by the organization or externally through legitimate training resources, such as the NYS Quality of Care Program or the Center for Quality Improvement and Innovation (CQII). Training should be designed to build capacity and capability of the workforce based on regular assessment and reassessment of staff knowledge and skills. Such training can be conducted on-site or off-site, during new staff orientations, or as part of regular staff meetings. As staff progresses along the continuum of QI sophistication, improvement is slowly integrated into clinic practice, enhancing staff engagement in the process. Immediate access to improvement data, for example, empowers staff to focus on key areas of care and build consensus around QI activities to improve patient outcomes.
As QI becomes part of the institutional culture and teamwork progresses, staff embrace their respective roles and responsibilities, acquiring a sense of ownership and deeper involvement in improvement work.
B.1. To what extent are physicians and staff routinely engaged in QI activities and provided training to enhance knowledge, skills, and methodology needed to fully implement QI work on an ongoing basis?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
Engagement of core staff in QI (clinical and non-clinical):
All staff (clinical and non-clinical) are not routinely engaged in QI activities and are not provided training to enhance skills, knowledge, theory or methodology or encouragement to identify opportunities for improvement and develop effective solutions.
Planning and initiation
1
Engagement of core staff in QI (clinical and non-clinical):
Is under development and includes training in QI methods and opportunities to attend meetings where QI projects are discussed.
Beginning implementation
2
Engagement of core staff in QI (clinical and non-clinical):
Is underway and some staff have been trained in QI methodology.
Includes QI meetings attended by some designated staff.
Implementation
3
Engagement of core staff in QI (clinical and non-clinical) includes:
Attendance in at least one training session about QI methodology. Staff members are generally aware of Program QI activities (quality plan/priorities).
Involvement in QI projects, project selection, and participation in a QI committee.
QI project development, where projects are discussed and reviewed during staff meetings.
Defined roles and responsibilities related to QI. Physicians and staff are aware of the quality plan and priorities for improvement.
A formal process for regularly recognizing staff performance in QI via performance appraisals, public recognition during staff meetings, etc.
Progress toward systematic approach to quality
4
Engagement of core staff in QI (clinical and non-clinical) includes:
Demonstrated evidence that staff members are engaged and encouraged to use those skills to identify QI opportunities and develop solutions.
A shared language regarding quality, which is evidenced in routine discussion.
Description in the annual quality plan and includes staff training and roles and responsibilities regarding staff involvement in QI activities and use in staff performance evaluation.
A formal process for recognizing staff performance internally, and QI teams are provided opportunities to present successful projects to all staff and leadership.
Full systematic approach to quality management in place
5
Engagement of core staff in QI (clinical and non-clinical) includes:
Staff awareness of the importance of quality and continuous improvement and their participation in identifying QI issues, developing strategies for improvement, and implementing strategies.
Regular and continuous QI education and training in QI methodology.
Leadership who encourage all staff to make needed changes and improve systems for sustainable improvement, including the necessary data to support decisions.
Formal and informal discussions wherein teamwork is openly encouraged and leadership shapes teamwork behavior.
Routine communication about new developments in QI, including promotion of QI projects both internally (e.g. quality conferences) and externally (e.g. related conferences).
Opportunities for abstract development and submission to relevant professional conferences and authorship of related publications about development and implementation of institutional QM programs.
B.2. To what extent is staff satisfaction included as a component of the quality management program?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started
0
There is no mechanism in place to assess and address staff satisfaction.
Planning and initiation
1
Staff satisfaction:
Is assessed through informal discussion with some staff.
Beginning implementation
2
Staff satisfaction:
Is part of a formal process that includes at least one staff satisfaction survey.
Implementation
3
Staff satisfaction:
Is part of a formal process where information is utilized to determine opportunities for improvement.
Survey results are reviewed with staff, and areas for improvement are identified.
Progress toward systematic approach to quality
4
Staff satisfaction:
Survey results are reviewed with staff, areas for improvement are identified, and planning is underway/work has begun to utilize this information to improve work conditions within the program.
Full systematic approach to quality management in place
5
Staff satisfaction:
Is measured in multiple ways (surveys, performance reviews, etc.), and information is utilized to improve work conditions within the ability of the program.
Survey results lead to improvement projects or activities through findings, and issues raised through staff feedback are prioritized in plans for improvement.
Is characterized by staff-directed QI project teams that are initiated based on data analysis with updates regularly communicated to leadership and all staff members.