NYS HIV Quality of Care Program Standards

Performance Measurement

Performance Indicators

Performance indicators guide the development and implementation of improvement activities. Indicators are chosen based on identified gaps in performance, internal HIV program priorities, and external expectations. At a minimum, indicators measure key health outcomes, such as viral suppression. The quality management plan describes these performance indicators, including their definitions, sources of data, desired health outcomes, and frequency of data collection. Indicator definitions are updated at least annually to reflect current standards of care and practices.

Performance Reviews

HIV program staff conduct and analyze the performance of core HIV services at least quarterly, with any more frequent measurements conducted based on identified needs for improvement. Additional measurement is conducted to fulfill reporting expectations of the New York State HIV Quality of Care Program. All Ryan White HIV/AIDS Program Part B-funded subrecipients are expected to submit performance measurement data for specified quality indicators to the AIDS Institute on a quarterly basis.

The HIV program generates and reviews newly diagnosed and established patient HIV treatment cascade data at least annually as delineated in HIV Organizational Treatment Cascades Annual Review Guidance. The program develops, measures, and revises process changes aimed at diminishing gaps identified by the cascades in linkage, engagement, treatment, and viral suppression outcomes to improve patient health and contribute to statewide goals aligned with the Governor’s ETE Initiative. The program reviews cascade-related quality improvement activities, at a minimum, on a quarterly basis.

Data Analysis and Follow-up

Performance data results are reviewed during quality management committee meetings to guide improvement activities. Data are disaggregated by key patient characteristics to identify potential disparities in HIV care and services, including, at a minimum, age, gender, exposure category, and race/ethnicity. An action plan to address performance gaps includes a description of implementation steps, specific responsibilities, and a timeframe for completion of activities. Performance data results are shared with staff, consumers, and key stakeholders.

Information System

The HIV program has an information system in place for tracking all people living with HIV – even if they are not receiving HIV care from the organization – and for monitoring patient care across the entire organization. The information system integrates electronic patient records, prescription, and laboratory records. The program’s information system produces meaningful performance data reports that include patient-specific and aggregate data on key quality of care indicators, such as viral suppression. The system is accessible to all relevant staff.

Data across information systems are coordinated. The program is encouraged to use data from Regional Health Information Organizations (RHIOs) to augment the analysis of information available internally to promote coordination of care and ascertain care status.