Dear Healthcare Provider:
We are pleased to provide you with this booklet describing the New York State HIV Quality of Care Program, which was launched by the New York State Department of Health AIDS Institute in 1992. This program is responsible for systematically monitoring the quality of medical care and support services provided to people living with HIV in New York State and for guiding care to achieve intended health outcomes.
Built upon the principles of continuous quality improvement, the program includes measurement of key performance indicators that have been defined by experts from the provider community. Priorities for these measures are jointly agreed upon by providers and consumers, together with state and local health officials. While we maintain attention to providing balanced healthcare, as our focus turns to ending the HIV epidemic, we are increasingly focused on three key indicators: linkage, retention, and viral load suppression. As part of the treatment cascade, these focal points are crucial to both preventing transmission of HIV and ensuring positive health outcomes.
This booklet provides an overview of the New York State HIV Quality of Care Program, which is involved with the measurement of quality indicators, the implementation of improvement methods, the presentation of facility-specific and statewide data, and the provision of quality improvement coaching services to support and develop HIV quality programs. Our learning networks and regional groups foster improvement through peer learning and targeted on-site coaching. Additionally, our web-based eHIVQUAL performance measurement system allows providers to generate immediate facility-level reports to drive their improvement activities. This New York State program has been a model for national improvement initiatives, specifically for the HIVQUAL-US program, which has now been integrated into the National Quality Center, supported by the Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB), and for global initiatives through HEALTHQUAL International.
The AIDS Institute is committed to building capacity and capability for quality improvement and has begun to expand its work to include improvement of hepatitis C and STI care in New York’s healthcare facilities. Although we have accomplished much, we still have work to do as we continue our mission in partnership with providers and communities to improve care, targeting our efforts to stem the HIV epidemic and end AIDS.
Bruce D. Agins MD, MPH
Medical Director, AIDS Institute
New York State Department of Health
AIDS Institute Mission and Vision
The AIDS Institute protects and promotes the health of New York State’s diverse population through disease surveillance and the provision of quality prevention, healthcare, and support services for those impacted by HIV, AIDS, sexually transmitted infections, viral hepatitis, and related health concerns. We are committed to eliminating new infections and improving the health and well-being of impacted communities.
The AIDS Institute is committed to the following guiding principles and core values:
Respect: We treat all individuals impacted by HIV, AIDS, sexually transmitted diseases, and viral hepatitis with dignity, respect, and compassion.
Partnership: We value community input and collaboration with federal, state, local, and community partners.
Leadership: We embrace, empower, and drive change in the fight against HIV, sexually transmitted infections, and viral hepatitis.
Stweardship: We strive to be creative and resourceful in planning, developing, and delivering high-quality services to impacted communities.
HIV Quality of Care Program Overview
The New York State Department of Health AIDS Institute is committed to promoting the quality of HIV clinical care and supportive services for people living with HIV/AIDS in New York State. The Quality of Care Program endeavors to:
- Accelerate measurable and continuous progress toward effective and consumer-centered HIV services, standards of care, and service delivery in alignment with the mission of the AIDS Institute, the National HIV/AIDS Strategy, and New York State Department of Health standards and guidelines for the care of people living with HIV/AIDS
- Facilitate improvement of HIV clinical care and supportive services to achieve positive health outcomes for people living with HIV/AIDS in New York State
To achieve these critical ends, the Quality of Care Program champions a quality management model that incorporates three core elements: continuous performance measurement; robust quality improvement activities; and quality management programs, which are defined as the structure, functions, and processes that support improvement activities. Through coaching, technical assistance, and the establishment of clinical indicators, the Quality of Care Program assists New York State HIV care providers in developing sustainable, independent quality management programs.
Current areas of focus for the Quality of Care Program include improving rates of viral load suppression, patient retention, and comprehensive mental health screenings, prioritizing health equity, and enhancing the use of clinical information systems to generate data to improve care. Refinement of measurement strategies to enhance clinical outcomes is also a major priority for the Quality of Care Program, as is ensuring the capacity of all New York State HIV programs to self-report their annual HIV performance data. To this end, the Quality of Care Program has developed a web-based performance measurement platform, eHIVQUAL, that enables HIV clinics to directly report their performance measurement data and to immediately view reports that facilitate identification of specific areas for clinical care improvement.
The capacity to continuously improve HIV treatment, care, and supportive services depends on a quality management infrastructure with the following features:
- Active support and guidance by clinical leadership and senior administration
- A written quality management plan
- Staff, physician, and consumer involvement in the quality management program
Standards for Quality of Care Programs
To guide providers in their establishment of sound quality management programs, the AIDS Institute has issued Quality of Care Program Standards that outline the expectations for HIV-specific quality programs. These standards were first drafted in 1995 and were most recently revised in 2012. They are integrated into all AIDS Insti – tute activities and are applicable to all HIV programs in New York State.
HIV quality management programs are actively supported and formally guided by clinical leadership and senior administration, which provides institutional commitment and allocates appropriate resources to ensure sustainable implementation of improvement activities.
Program staff are aware of the quality management infrastructure and understand their roles in improvement activities.
An HIV quality management committee is fully accountable for HIV-specific improvement activities, development of annual quality improvement goals, prioritization of key quality indicators for review, sharing of HIV performance data with staff and stakeholders, and routine evaluation of the quality management program. The committee membership includes staff from all key medical and nonmedical services. Consumer representatives are included to provide input to ensure that services effectively meet or exceed patient needs and expectations. The committee meets at least once every other month.
HIV quality management programs are effectively linked with the institution-wide quality management program. Each HIV quality management program has a written annual quality management plan that is reviewed and updated routinely by the quality management committee.
The plan includes the following elements:
- A quality statement describing the overall mission of the quality management programn
- A description of quality management infrastructure and leadership responsible for program-wide quality management initiatives, including: the internal and external quality management committee(s) structure; committee chairperson; membership; meeting schedule to assess progress and plan future activities; and a plan for communicating the quality management program activities. The major stakeholders and their expectations for the quality management program should also be identified, in addition to the resources and staffing allocated for quality management program activities.
- Performance measurement activities describing indicators and data collection methodologies n Annual improvement goals based on program priorities
- Processes for training and engagement of staff, consumers, and stakeholders
- Procedure(s) for routine evaluation of the quality management program. The plan is shared with staff and consumers to gather input and to promote involvement in the quality management program and its activities.
- A formal workplan that identifies implementation responsibilities and a timetable for their completion. The workplan is revised routinely as part of periodic review and formal evaluation.
Performance indicators should guide the development and implementation of improvement activities. 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.
HIV program staff analyze the performance of core medical and nonmedical services at least annually and conduct more frequent measurements based on identified needs for improvement. Indicators are chosen based on internal HIV program priorities and external expectations. At a minimum, indicators measure key health outcomes, such as viral load suppression.
Performance data results are reviewed during quality management committee meetings and are used to guide improvement activities. An action plan to address performance gaps includes a description of implementation steps, specific respon – sibilities, and a time frame for completion of activities. Performance data results are shared with staff, patients, and key stakeholders.
Each HIV program has a functional information system for tracking patients and monitoring patient care. The information system produces meaningful performance data reports that include patient-specific and aggregate data on key quality of care indicators, such as viral load suppression and retention in care. The system is accessible to staff for routine data review and for generating customized data reports that can then be used to assess the quality of HIV care.
Each HIV program selects at least one new improvement project annually. Improvement activities are identified and prioritized by the quality management committee and are based on performance data results, external expectations, and consumer and staff input.
The quality management committee oversees the progress of internal quality initiatives and any necessary actions in response to external audit findings.
Improvement teams with cross-functional representation, including consumers, are formed to address specific improvement opportunities and to monitor changes. Results of improvement projects are presented to the HIV quality management committee, shared among staff and consumers, and used for future planning.
The quality management committee and improvement teams comprise staff members representing all disciplines, including medical providers.
Job expectations and descriptions require staff involvement in quality management activities.
Staff participate in capacity-building activities, such as learning networks or regional groups, which promote peer learning and accelerate improvement project implementation.
The objectives, progress, and results of improvement activities are routinely communicated to staff to increase awareness and participation in the HIV quality management program.
At a minimum, annual improvement training or updates are provided to staff to further build their capacity for quality improvement.
Consumers are included in improvement activities, and their input is considered in the selection of improvement priorities. Consumer involvement in quality activities should include: membership on the HIV quality management committee, participation on improvement teams, review of performance data results, coordination of the consumer advisory committee with the quality management committee, and implementation of specific improvement activities aimed at improving the quality of clinical care. Providers actively encourage consumers to participate as quality team members in learning network and regional group activities.
Organizational Assessments (OAs)
Development, implementation, and spread of sustainable quality improvement (QI) throughout an HIV program require an organizational commitment to the quality management program, wherein structures, processes, and functions support measurement and improvement activities. Organizational infrastructure is fundamental to QI success and involves a receptive organization, sustained leadership, staff training and support, time for teams to meet, and data systems for tracking outcomes.
This structure supports quality initiatives that apply robust process improvement including: reliable measurement, root cause analysis, and finding solutions for the most important causes identified.
The scoring structure measures program performance in specific domains along the spectrum of improvement implementation.
The OA is implemented in two ways: 1) by an expert QI coach or 2) as a self-evaluation. The results are ideally used to develop a workplan for each element, with specific action steps and timelines to guide the planning process and focus on priorities, setting direction, and ensuring that resources are allocated for the quality manage – ment program. Whether performed by a QI coach or applied as a self-evaluation, key leadership and staff should be involved in the assessment process to ensure that all key stakeholders have an opportunity to provide important information related to the scoring.
Results of the OA should be communicated to internal key stakeholders, leadership, and staff. Applied annually, this assessment helps a program evaluate its progress and guides the development of goals and objectives.
Quality of Care Program Components
The AIDS Institute Office of the Medical Director convenes advisory committees of stakeholders to promote, monitor, and support the quality of HIV clinical services for persons living with HIV in New York State. The following committees have been established to provide expertise and guidance to the Quality of Care Program.
The Quality Advisory Committee provides the AIDS Institute with expert advice regarding the development and implementation of the Quality of Care Program. Since 1992, the Committee has met quarterly and is composed of clinicians who represent HIV medical care clinics from all regions of the state, including Designated AIDS Centers, community health centers, and drug treatment centers. Clinicians with expertise in management of sexually transmitted infections (STIs) and hepatitis are also members, along with leaders of Ryan White Part A service programs and the Department of Corrections and Community Services (DOCCS). The Quality Advisory Committee advises the Quality of Care Program on the selection and refinement of clinical indicators that are aligned with clinical guidelines. In addition, the Committee offers guidance on performance review criteria, policy decisions, and issues related to the quality of HIV care. Current areas of focus include patient retention, viral load suppression, coordination of care, STIs, adolescent transition into adult care, and the use of electronic health technologies and regional health information organizations (RHIOs) to generate useful performance data
Input from persons living with HIV/AIDS is an integral component of New York State’s Quality of Care Program. The Consumer Advisory Committee (CAC) was established in 2002, and its members represent the diversity of people living with HIV/AIDS in New York State in terms of geography, gender, race, ethnicity, disability status, socioeconomic status, and exposure category. At quarterly meetings, CAC participants discuss regional quality of care issues from a consumer perspective and consider strategies that can effectively empower relationships with providers. Key topics and issues addressed include recommendations for the creation or revision of HIV performance measures and prioritization of statewide quality improvement initiatives. The committee also reviews clinical guidelines and educational materials. To address the particular needs of young people living with HIV/AIDS and to gain their input, the CAC helped to establish the Young Adult Consumer Advisory Committee in 2008.
|Quality Advisory Committee and CAC Joint Activities|
Together, the Quality Advisory Committee and Consumer Advisory Committee form a partnership wherein each committee provides perspective and insight into quality of care and indicator development. The close relationship challenges the patient-provider dichotomy that often hinders quality of care discussions. Recent joint Quality Advisory Committee and Consumer Advisory Committee activities include:
Beginning in 2000, the AIDS Institute and the New York City Department of Health and Mental Hygiene established a partnership to provide quality management services to Part A–funded programs in the New York Eligible Metropolitan Area (EMA). Because most of these programs provide HIV supportive care services in a variety of service categories, the Part A Quality Management Program has developed distinct approaches in working with Part A providers and the consumers they serve. In the past two years, the Part A Quality Management Program has developed new quality indicators for each service category and expects to use annual performance review data to accelerate improvement. It also works to assist Part A providers in developing quality infrastructure and provides guidance and support to sustain quality efforts by working collaboratively to address the needs of people living with HIV/AIDS across the HIV care continuum.
In New York State, over 25,000 people each year have access to lifesaving HIV medications through the AIDS Drug Assistance Program (ADAP). New York State employs a comprehensive prospective and retrospective approach to clinical quality management, including quarterly reviews of individual and pharmacy filling patterns to determine medically inappropriate or insufficient regimens. Interventions are initiated with providers to improve patient safety and to modify regimens as required. Data collection strategies include using pharmacy and primary care claims data to assess appropriateness of care.
The Quality of Care Workgroup comprises internal AIDS Institute stakeholders, including the Healthcare Division, the Office of the Medical Director, the Division of HIV/STD/Hepatitis C Prevention and Epidemiology, and the Office of Medicaid Policy and Programs. Meeting monthly, the workgroup discusses and reviews all Quality of Care Program activities and results, identifying opportunities for improvement and for increased capacity building among New York State HIV providers. Areas of focus include the development of processes to assist low-performing clinics in improving the quality of care that they provide, developing and refining the Quality of Care Standards, engendering peer learning opportunities through quality learning network activities, and developing and refining quality of care campaigns and special initiatives.
Since 1991, the AIDS Institute has championed the use of modern quality improvement methods throughout the New York State healthcare delivery system. Providers are encouraged to analyze data and assess the internal factors that contribute to organizational performance, ultimately reducing process variation and maximizing desired outcomes while working to achieve measurable goals.
To build capacity and capability for quality improvement in HIV care, the Quality of Care Program offers coaching and technical assistance to all New York State healthcare facilities. Working with clinicians and administrative staff, the AIDS Institute quality coaches help HIV care providers to:
- Develop and implement sustainable quality management structures and processes for ongoing internal performance monitoring and improvement activities
- Measure performance data and analyze and interpret data results
- Continue their education in quality improvement methods and promote collaborative work of the healthcare team, including physicians and patients, in developing innovative improvement strategies
Quality of Care Program staff regularly review recent eHIVQUAL and Organizational Assessment data from HIV providers to identify programs to inform coaching needs. HIV providers are also encouraged to request assistance when they recognize a need for increased quality management capacity building. Programs with low scores across key indicators, such as viral load suppression and retention, are given the highest priority. Those providers in need of developing an HIV quality management infrastructure also receive high priority.
Adapted from the Institute for Healthcare Improvement’s Breakthrough Series collaborative, regional groups and learning networks combine ongoing quality coaching with structured one-day or half-day group meetings that focus on quality management and peer exchange. Regional groups and learning networks are designed to promote strategies to improve quality of care and health outcomes by strengthening provider infrastructure and increasing competency in performance measurement and quality improvement methodology. This model provides an efficient structure to convene groups of HIV providers on an ongoing basis, thereby facilitating peer learning, sharing of improvement activities, and identification of common programmatic challenges. Regional groups and learning networks also allow identification of specific local priorities for improvement and foster coordination of clinical and nonclinical agencies in improvement activities.
NY Links regional groups consist of HIV clinical, service, and prevention providers within a geographic area who, together with community members living with HIV and public health professionals, collaborate to end HIV transmission and HIV-related mortality. Using modern improvement science and local epidemiological data, these groups aim to improve linkage to and retention in HIV primary care, to optimize viral load suppression, and to improve both individual and community health outcomes.
- NY Links regional groups will reduce the transmission of HIV across New York State by:
- Implementing a community-based response to the HIV epidemic by mobilizing networks of clinical and nonclinical providers, community leaders, and community members living with or affected by HIV/AIDS
- Aligning programs, providers, and the community to address the goals of New York State to end the HIV epidemic through shared local leadership and with technical support from state and local health departments
- Building capacity for quality improvement in the region, identifying and disseminating successful interventions within the continuum of HIV services, and sustaining the achieved regional results
- Using community-level data to link public health strategies with clinic and service-level improvement initiatives
Performance measurement involves the systematic process of data collection to track patient outcomes, thereby ensuring that programmatic changes can be data driven and that ineffective solutions can be identified and avoided. Performance measurement also provides a method for monitoring improvements and establishing a baseline for performance comparisons across sites. Quality of Care Indicators The Quality of Care Program measures performance based on indicators that are linked to optimal clinical care outcomes. These specific aspects of clinical care are selected by the Quality Advisory Committee or subcommittees in conjunction with the Consumer Advisory Committee and approved by the Medical Director as priorities for measuring quality in HIV care. Indicators are subsequently developed and reassessed in accordance with evolving medical and public health priorities. Some indicators apply to all persons living with HIV, whereas others apply only to specific population groups. A set of measures pertaining to adolescent HIV care was developed in 2010.
The Quality of Care Program measures performance using data submitted through the web-based eHIVQUAL application. Launched in 2009 and developed through support from the Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB) and HIVQUAL-US, eHIVQUAL facilitates the collection, analysis, and reporting of HIV clinical data according to clinical practice guidelines and indicators developed by the AIDS Institute and its expert advisory committees. Performance data are submitted from over 200 healthcare facilities throughout New York State. Data collection methodologies are based on well-established performance measurement sampling tools and are standardized across all HIV facilities. The results of these reviews are instantly available through reports in the application so that providers can immediately use their data findings to prioritize upcoming quality activities. Each site also receives an individualized report containing its scores and benchmarking data from all New York providers. Data are aggregated to calculate mean scores and percentiles, which are used to target providers for assistance and consultation. The AIDS Institute also regularly releases benchmarking data reports that compare the quality of care across different regions of New York State.
As part of New York State’s commitment to transparency of data, the finalized eHIVQUAL performance data report from HIV ambulatory care programs is available online. For more information, visit Health Data NY.
Physicians who are engaged in quality improvement through the New York State Quality of Care Program may be eligible to earn twenty points of maintenance of certification (MOC) Part IV practice credit from their medical specialty board(s). This program offers a streamlined pathway to MOC that reduces redundancy and champions leadership for improvement implementation.
2016 NYS HIV Quality of Care Review
- 2016 NYS Quality of Care Program Review Announcement
- 2016 NYS Quality of Care Program Review: Cascade Guidance Release
- 2016 NYS Quality of Care Program Review: eHIVQUAL Guidance Release
The 2016 New York State HIV Quality of Care Program Review will be conducted in early 2017 with a first deadline for submission of March 31, 2017. Based on the recommendations of the NYS HIV Quality of Care Clinical Advisory Committee and its Ending the Epidemic Subcommittee, this year the Review will use a dynamic new approach geared to help providers move quickly from performance measurement to quality improvement and focus on activities directly linked to the Governor’s Ending the Epidemic Initiative. Viral load suppression, antiretroviral therapy, and STI indicators will be included in the eHIVQUAL online application. In addition, providers will be expected to submit the following:
- Organizational HIV treatment cascades
- Plans to improve aspects of HIV care as indicated by the cascades
- Results of a stigma survey focusing on organization-level characteristics
- Tobacco cessation campaign data
We hope that organizations will find the Review a rewarding process, and we look forward to partnering with them in our ongoing efforts to improve the quality of HIV care in New York State. Successful completion of this review will help us achieve our goal to end the epidemic in New York State by 2020 and contribute to New York’s role in meeting the aims of the National HIV/AIDS Strategy.
Organizational HIV Treatment Cascades
The Cascade was originally developed to conceptualize population-level deficiencies in HIV care but has recently been adapted to address the effectiveness of HIV treatment at the level of an individual organization. Created by the Office of the Medical Director at the NYSDOH AIDS Institute in support of Governor Andrew Cuomo’s three-point plan to end the AIDS epidemic in NYS by 2020, this adaptation provides organizations with a standardized tool to:
- Monitor the extent and quality of care being delivered to all HIV-positive patients seen at an organization, and not just those that are actively engaged in their HIV program;
- Identify gaps (“leaks”) in the sequences of steps between diagnosis and VLS as they are delineated by the Cascade; and
- Develop data-driven plans to assess and improve these gaps through QI activities
Organizational cascades will be reviewed by Quality of Care Program staff in the Office of the Medical Director. Feedback will be provided to guide the integration of the cascades into organizations’ ongoing QI programs. For additional information, please see Resources, listed above.
eHIVQUAL Patient-Level Data Submission
This year’s eHIVQUAL quality review of ambulatory care services focuses on a narrower range of indicators. In keeping with the Governor’s plan to end the epidemic by 2020, all organizations are expected to submit data on three main indicators: viral load suppression, prescription of ART, and treatment of sexually transmitted infections.
All patients will be included in the reviews of viral load suppression and ART prescription (with limited exceptions pertaining to incarceration or patients receiving ongoing care at another organization), whereas a sample of active patients will be sufficient for the STI measures. Please note that each individual organization, as defined as a specific “site,” like last year, is expected to submit eHIVQUAL data. Also, please note that cascades may be submitted by a network of organizations, following discussion with the AIDS Institute Quality of Care program staff. Additional guidance can be found at www.ehivqual.org.
Tobacco Cessation Campaign
The 2016 Quality of Care Program Review also includes a component focused on tobacco cessation. Based on recommendations from the Clinical (QAC) and Consumer (CAC) Advisory Committees the Tobacco Cessation Campaign strives to prioritize tobacco cessation among people living with HIV. As a part of the Review, providers are expected to complete quarterly reporting on tobacco cessation measures for all patients living with HIV (PLWH) beginning April 1st, 2017 until March 1st, 2018. The purpose of this campaign is to promote tobacco screening and tobacco cessation with the goal of improving health and decreasing morbidity and mortality of PLWH in New York State. Guidance on this component of the Review is forthcoming.
Stigma Reduction Campaign and Survey
As a part of the 2016 Quality of Care Program Review, all practice sites providing care to HIV-positive patients in NYS are expected to complete a stigma reduction initiative, which includes both a facility-focused stigma survey and a stigma reduction action plan, as a part of their annual QI data submissions to the New York State Department of Health AIDS Institute. Guidance on this component of the Review is forthcoming.
Web Resources and Suggested Reading
BMJ Quality: An online workspace for the creation of healthcare improvement programs.
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, by Gerald Langley, et al (Jossey-Bass, 2009): A bestselling guide to integrated process improvement
Improving Quality Together: The national quality improvement learning program for the National Health Service of Wales.
Institute for Healthcare Improvement: An independent, not-for-profit healthcare improvement organization based in Cambridge, MA.
Intermountain Healthcare: A network of hospitals in Utah and Idaho with an innovative array of quality improvement programs.
Jönköping Academy for Improvement of Health and Welfare:
A Swedish collaborative research and education center focused on quality improvement and leadership.
National Quality Center: A free quality improvement technical assistance resource in HIV care for all Ryan White Program–funded grantees.
NHS Scotland: Scotland’s publically funded healthcare system.
Quality Improvement Made Simple by the Health Foundation (2013): A quality improvement guide created by an independent charity working to improve healthcare in the United Kingdom
The Team Handbook, third edition, by Peter R. Scholtes, et al (Oriel Inc., 2003): A comprehensive resource for team-based quality improvement
Understanding Variation: The Key to Managing Chaos, second edition, by Donald J. Wheeler (SPC Press, 2000): A guide to data analysis in the context of quality improvement
University Research Company: A global organization focused on improving quality in healthcare, health education, and social services.