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 and more frequent measurements based on identified needs for improvement and as needed to fulfill reporting requests made by the AIDS Institute Quality of Care Program. At a minimum, indicators measure key health outcomes, such as viral suppression.

The HIV program generates, and reviews newly diagnosed and established patient treatment cascade data at least annually. Programs are expected to develop, measure, and revise process changes aimed at diminishing gaps in linkage, engagement, treatment, and viral suppression outcomes to improve patient health and contribute to statewide goals aligned with the Governor’s EtE Initiative, as well as the AIDS Institute goal to sustain gains and continuously improve care for people living with HIV.

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 a functional and efficient information system in place for tracking all HIV-infected patients--even if they are not receiving HIV care from the organization--and for monitoring their patient care across the entire organization. The information system integrates electronic medical records systems, prescription and laboratory records, and billing data. 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. The program is encouraged to use data from local public health departments or Regional Health Information Organizations (RHIOs) to augment the analysis of information available internally.