June 2004

Dear Healthcare Provider:

We are pleased to provide you with this booklet describing the New York State Department of Health AIDS Institute’s HIV Quality of Care Program. This program is responsible for the systematic monitoring of the quality of medical care and support services provided to people with HIV infection in New York’s hospitals, chronic care facilities, community health centers, drug treatment programs, and community-based organizations, as well as through HIV Special Needs Plans. Created in 1992, and built upon the principles of continuous quality improvement, the program includes measurement of data in key performance areas that have been defined by experts from the provider community. This booklet provides an overview of the Department of Health’s program, including measurement of quality indicators, its model for quality improvement (HIVQUAL), presentation of facility-specific and statewide data, and provision of consultation services to support and develop HIV quality programs.

The AIDS Institute is committed to building capacity and capability for quality improvement. We hope this booklet will both acquaint HIV providers with the AIDS Institute’s HIV Quality of Care Program and guide them as they develop and strengthen their own quality improvement programs.

Sincerely,

Bruce D. Agins, MD, MPH
Medical Director
AIDS Institute

THE HIV QUALITY OF CARE PROGRAM

The New York State Department of Health AIDS Institute (NYSDOH AI) is committed to promoting the quality of HIV clinical care and supportive services delivered to people with HIV in New York State. The Office of the Medical Director collaborates with HIV clinical and support service providers, persons living with HIV, AIDS Institute program management staff, and peer reviewers to evaluate the quality of HIV care provided in New York State. Currently, over 150 healthcare facilities have been reviewed, including chronic care facilities, Designated AIDS Centers (DACs) and other hospitals, primary care centers, drug treatment programs, adult day treatment programs, and community-based programs. Reviews of HIV Special Needs Plans (SNPs) are now also underway.

The Office of the Medical Director coordinates the participation of several distinct groups to accomplish the Program’s goals: (1) the HIV Clinical Guidelines Program, responsible for the development of adult and pediatric clinical guidelines; (2) the HIV Quality of Care Advisory Committee, responsible for selecting indicators and defining review criteria; (3) a performance measurement program that includes a medical record review; (4) the Quality of Care Workgroup based at the AIDS Institute, responsible for implementation and refinement of the program; (5) the HIV Special Needs Plans (SNPs) Quality Committee; (6) the New York City Title I Quality Management Program Advisory Committee; and (7) the HIV Consumer Advisory Committee (see Figure 1). This dynamic process allows New York State to sustain its partnership with the HIV provider and consumer communities and remain responsive to the continuously changing nature of HIV clinical management.

Figure 1: AIDS Institute HIV Quality of Care Program

INVOLVING CONSUMERS

Participation by people living with HIV is an integral component of the AIDS Institute’s Quality of Care Program.

Through its Consumer Initiative, the HIV Quality of Care Program is intensifying its efforts to further include people living with HIV in planning, implementing, and evaluating quality of care program activities. Specific objectives for this initiative include:

• Facilitation of a statewide Consumer Advisory Committee to provide input for the AIDS Institute’s Quality of Care Program
• Solicitation of feedback and recommendations about the AIDS Institute’s HIV Quality of Care Program
• Incorporation of the priorities of consumers into the HIV Quality of Care Program
• Education of consumers about quality improvement and performance measurement

The HIV Consumer Advisory Committee (CAC) represents diverse communities affected by the HIV epidemic in New York State. At its meetings, consumers discuss quality of care issues that affect them and strategies that can effectively empower them in their relationships with providers. The committee is currently working on strategies to integrate prevention into HIV primary care, increase consumer involvement in quality improvement programs, establish performance measures, participate in guideline reviews, and interact with SNP medical directors. Committee representatives attend the AIDS Institute’s Quality of Care Advisory Committee meetings.

Activities have been launched that specifically focus on consumers of HIV health care. The first of these is the development of a consumer companion guide to assist consumers in understanding different rates of quality performance at ambulatory care facilities in New York State. The second of these is the development of a curriculum designed to assist consumers in the use of information to strengthen their decision-making about health care as well as their skills in negotiating with clinicians. The third activity is the development and publication of the first validated HIV-specific Patient Satisfaction Survey for HIV Ambulatory Care, which includes modules for HIV primary care, case management, women’s health, mental health services, substance use services, and Medicaid Managed Care.

PERFORMANCE MEASUREMENT

Indicators

The measurement of quality of care is based on indicators that are linked to optimal clinical care outcomes. Specific aspects of clinical care are selected by physicians through formal decision-making strategies as priorities for measuring quality in the medical records of individuals infected with HIV. From these aspects of care, indicators are developed. Some indicators apply to all persons with HIV, whereas others apply only to specific population groups, and still others apply only to those with specific conditions or diseases. Indicators can therefore be applied on the basis of age, gender, or diagnosis. Although Medicaid patients constitute a large proportion of the reviewed, or sampled population, patients representing all payers are reviewed including Medicaid Managed Care enrollees, Ryan White-funded providers, and ADAP enrollees (see Appendix for definitions of core clinical indicators).

Keeping up to date with the changing field of HIV medicine and the dynamics of the healthcare delivery system stands out as an important priority of the HIV Quality of Care Program. To meet this demand, the HIV Quality of Care Advisory Committee frequently discusses changes in HIV clinical management and recommends modifications to indicators to ensure that they remain current. Recent examples of this process include the change from a simple analysis of whether antiretroviral therapy has been offered to how it is used and monitored, the inclusion of a hepatitis C screening measure, and the development of an indicator that measures assessment of mental health screening for people with HIV in primary care settings.

For additional information regarding the necessary steps to develop HIV specific indicators, please refer to Measuring Clinical Performance: A Guide for HIV Health Care Providers. This publication has been developed in collaboration with the AETC National Resource Center and is available at www.hivguidelines.org.

Performance Data

Data generated from quality of care facility reviews are reported to facilities so that they can evaluate the systems of care at their institutions. In keeping with the New York State Department of Health’s goal of promoting equal access to health care for all New Yorkers, the AIDS Institute analyzes the data that it collects to determine whether disparity in access to care exists among different groups, including gender, race/ethnicity, exposure category, and age. Performance data are then used to facilitate healthcare system planning and to set priorities for establishing services.

The trellis diagram below is an example of the presentation of performance data derived from reviews of individual facilities for one HIV quality indicator. Presenting data in this format enables facilities to view trends in their performance and also to engage in comparative evaluation and benchmarking analysis.

Quality of Care Indicator Trellis Diagram

Each panel corresponds to one healthcare facility, and each dot within each panel represents the performance result for a particular year. Dots at the top of each panel represent more recent reviews, while dots at the bottom of each panel represent older reviews. Performance rates are measured from left to right within each panel, with 100% performance being represented by a dot at the far right. A favorable trend is depicted by dots moving toward the right as one reads from bottom to top in each panel.

The Quality of Care Review Program utilizes the following statistical methods to ensure that performance data are analyzed and presented to yield the highest degree of precision:

Inter-rater Reliability: Inter-rater reliability measures the rate of agreement among medical record abstractors to assess the reliability of data collected by different abstractors.

Finite Population Correction: This statistical adjustment tool takes into consideration the proportion of records reviewed at a facility to the total number of records eligible for review, in order to develop more precise estimates with narrower confidence intervals. This tool is particularly useful for analysis of data from facilities with smaller HIV caseloads.

Bayesian Estimates: Bayesian estimation techniques increase precision by incorporating prior information. In this case, previous sample results are incorporated into current quality scores. This effectively increases the size of the sample being considered, thereby reducing variance.

Title I HIV Quality Management Program

In 2001, the AIDS Institute was awarded a contract through the New York City HIV Health & Human Services Planning Council (Ryan White Title I) to measure the quality of health and supportive services. This program was created as a result of the reauthorized Ryan White CARE Act, which directs grantees to establish and implement quality management programs. This legislation recognizes for the first time the importance of monitoring the quality of supportive services funded through Title I programs and their importance in providing stable living environments and supportive services that enable people living with HIV to successfully adhere to complex HAART regimens. The Title I HIV Quality Management Program has been built upon the existing infrastructure for quality management in New York State.

The AIDS Institute has developed performance measures for many of the services funded by the Planning Council, which include health, mental health, social services, alcohol and other drugs, and housing. Formal decision-making methods have been employed in the process of indicator development to ensure participation of all funded agencies. To date, performance measurement has occurred at facilities receiving Ryan White Title I funding for health-related services, including adult day treatment, home care, and treatment education; as well as in facilities receiving funding for mental health care and case management. Reviews will commence in other Title I-funded service areas once indicators specific to those areas have been developed.

This new quality of care program offers a comprehensive portfolio of clinical and supportive services indicators, an incentive for providers of supportive services to monitor and improve the quality of services that they offer, and the tools with which these improvements can be made.

HIV Clinical Performance Data Release

In keeping with the New York State Department of Health’s commitment to provide comparative information about health care to the public, the HIV Quality of Care Program issued the first public release of HIV clinical performance data in 2000 and followed it with a second edition in 2004. These reports marked the first-ever release of HIV performance data in the United States. Included in these public releases were the clinical performance data that the AIDS Institute collected from over 150 healthcare facilities across New York State that provided HIV clinical care.

The first edition of this report was issued in July 2000 and contained data collected from 1996 to 1998. The second edition, issued in 2004, includes data collected from 1999 to 2001. This report recognizes facilities that achieved high performance rates, encourages facilities with lower performance rates to improve, and provides consumers and community-based organizations with performance data. A detailed booklet for providers and a companion guide for patients in English and Spanish have been developed to present the data, explain each measure, and offer guidance in the interpretation of the data. A training program has also been developed to facilitate interpretation.

QUALITY IMPROVEMENT

The quality improvement approach utilized by the AIDS Institute emphasizes systems of care rather than individual practitioners, a multidisciplinary team approach, and a continuing cycle of improvement activities and performance measurement. Providers are encouraged to analyze data and assess the internal factors that contribute to organizational performance. Results generated through the review program are also used by the State to target providers for assistance and consultation. A quality improvement consultation service designed by the AIDS Institute is available to assist facilities in the development of their own HIV quality improvement programs.

HIVQUAL

The AIDS Institute developed a model of on-site quality improvement consultation to assist healthcare facilities with developing and sustaining their quality improvement programs, which has since evolved into the HIVQUAL Model (see Figure 2). This model emphasizes the crafting of an organizational structure and quality improvement plan to support quality improvement and performance measurement activities. The ultimate goal of this activity is to build an independent quality improvement program that is sustainable and can be used in an ongoing dynamic way to continuously analyze and improve care (see Tables 1 & 2).

Figure 2: HIVQUAL Model

In New York, a statewide consultation service provides assistance to HIV healthcare facilities. Sponsored by the AIDS Institute, this service is supported by additional funding from the New York City HIV Health & Human Services Planning Council (Ryan White Title I). The main goal of the QI consultant is to help facilities build capacity and capability for quality improvement in HIV care through the development of QI systems (see Figure 2).

Table 1: The HIV Quality Program

The National HIVQUAL Project is sponsored by HRSA’s HIV/AIDS Bureau, Division of Community-Based Programs, Ryan White Title III and IV Programs, which fund the AIDS Institute to build capacity and capability among Title III and Title IV grantees to sustain quality improvement. A software program, HIVQUAL3, has been developed through this Project and is used as a tool to facilitate measurement of quality.

The HIVQUAL Model (see Figure 2) is based upon several key principles:

• Promotion of ongoing quality improvement activities to improve patient care
• Performance data lays the foundation for quality improvement
• Infrastructure permits systematic implementation of quality improvement activities
• Indicators are based on clinical guidelines or identified through formal group decision-making methods
• Encouragement of self-reporting of HIV performance measurement data
• Individualized consultation permits individualized responsiveness to specific organizational needs

In addition to building their quality program, grantees are coached to develop specific skills in measurement, sampling, identifying opportunities for improvement, and conducting improvement projects to improve performance. Once these skills are learned, they can easily be applied to measure other indicators and to other programs in the organization. The six-step model for developing a quality project is depicted in Table 2.

New York State HIVQUAL participants also have the additional resource of access to regularly scheduled HIVQUAL workshops and peer learning opportunities. Intended to provide hands-on, interactive learning experiences to facilitate the development of core skills in quality improvement, the workshops offer participants the opportunity to meet with other providers and to exchange ideas, experiences, and best practices in an informal, lively setting. Examples of exercises used in the HIVQUAL workshops have been published in the HIVQUAL Group Learning Guide. This publication promotes quality improvement via 20 concrete exercises and includes a facilitator guide. Additional modules for the Group Learning Guide are available on the AIDS Institute website: www.hivguidelines.org.

Table 2: The HIV Quality Improvement Project

As New York State HIVQUAL participants achieve a significant, demonstrated mastery of QI tools and methods, they become eligible to be considered an advanced or independent HIVQUAL site. With the attainment of this status, providers have access to regularly scheduled conference calls and workshops that address issues of interest to advanced providers and move beyond the core indicators measured in the HIVQUAL Project. This collaboration among independent HIV programs facilitates provider peer learning through the open exchange of ideas for solutions and creation of a forum for discussion of successful strategies.

Further information about the HIVQUAL Project may be obtained by calling the AIDS Institute at (212) 268-6108, or accessing the website at www.hivguidelines.org.

HIVQUAL3 Software

The HIVQUAL Project offers, at no cost, HIVQUAL3 software designed to facilitate monitoring of clinical care. This software includes indicators based on clinical practice guidelines developed by the New York State Department of Health AIDS Institute, its expert advisory committees, the Title I HIV Quality Management Program, and the Titles III and IV Project Advisory Committee. Performance data collected during this process are validated by external chart review.

Quality indicators included in the HIVQUAL3 software:

• HIV Monitoring (CD4 Count and Viral Load)
• ARV Therapy Management
• ARV Treatment Education
• Adherence to ARV Therapy
• Gynecologic Examinations
• Mycobacterium tuberculosis Screening (PPD)
• Hepatitis C (HCV) Screening
• Substance Use Assessment
• Mental Health Assessment

Networks

In 2004, the AIDS Institute initiated Quality Learning Networks to meet the demand for defined, measurable accelerated improvement in the care of individuals living with HIV. Modeled on the Institute for Healthcare Improvement’s Breakthrough Series Collaboratives, the Learning Networks combine methods and methodologies of rapid change, peer learning, and individualized consultation. The goals of a Network are to improve the quality of HIV care and services within participating facilities, to achieve measurable desired program outcomes, to strengthen the quality infrastructure, to create a peer learning environment, and to rapidly spread improvements throughout the participating agencies. The following Networks have been initiated:

• Health and Hospitals Corporation (HHC) HIV Quality Learning Network
• Substance Use Learning Network
• Ryan White Title I Mental Health Quality Network
• Ryan White Title II Mental Health Quality Network
• Adult Day Care Quality Network

Based on the Quality of Care Program Standards, the AIDS Institute developed an Organizational Assessment Form (see Table 3) incorporating the following domains: Quality Structure, Quality Planning, Performance Measurement, Quality Improvement Activities, Staff and Consumer Involvement, and Evaluation of the Quality Program. The standardized review tool provides an opportunity to assess infrastructure, evaluate progress over time, and compare different quality programs. The Quality of Care Program initiated a process to review all HIV programs in New York State.

Table 3: New York State Quality of Care Assessment Tool

A formal quality of care program that embraces quality improvement (QI) philosophy should be developed and implemented as part of the HIV service delivery program. An effective HIV quality improvement program includes the following components:

• The infrastructure of the quality program should be fully described in the quality plan, with a clear indication of responsibilities and accountability, and elaboration of processes for ongoing evaluation and assessment.
• Staff should be actively involved in the HIV Quality Program and its QI activities. Participation in the quality program should be part of job expectations. Provisions should be made for ongoing education of staff about quality improvement.
• Performance measurement should include clearly defined indicators that address clinical, case management, and other services as prioritized by the program. A plan for follow-up of results should be outlined.
• QI activities should be based on performance data results. Specific QI projects should be undertaken which include action steps and a mechanism for integrating change into routine activities.
• Consumers should be included in quality-related activities

CONCLUSION

The New York State Department of Health AIDS Institute’s HIV Quality of Care Program emphasizes three principal areas of quality management: 1) performance measurement, 2) quality improvement, and 3) quality infrastructure development. This comprehensive program involves the coordinated participation of numerous stakeholders and leaders, including clinicians, service providers, consumers, and AIDS Institute staff. Each group offers valuable perspectives and provides important contributions that result in achievement of the highest quality of care for people living with HIV.

Several important priorities have emerged for the HIV Quality of Care Program during the past two years, including management of antiretroviral therapy, retention of patients in care, integrating prevention into care, coordination of care, promoting consumer involvement in QI planning and activities, and establishing minimum standards for clinical information systems. With the continued participation of the key stakeholder groups, the AIDS Institute intends to continue championing quality improvement as a strategy to improve the HIV healthcare system while continuously improving patient care.

APPENDIX

I. Core Clinical Indicators (Adults)

A. Antiretroviral Therapy – Related Indicators
(appropriate management of ARV therapy, treatment adherence, care by an HIV Specialist)

General Eligibility: Patients who are either receiving ARV therapy, received ARV therapy in the past, or are eligible for ARV therapy based upon current New York State ARV therapy guidelines. Patients hospitalized and with no ambulatory clinic visits during any 4-month review period are not eligible for review during that period.

Appropriate management for patients stable on ARV therapy

Eligibility: Viral load is undetectable; or has dropped by at least one log since last 4-month review period; or has increased by less than 3x the lowest value in last 12 months on that regimen; or there is a note in record by treating physician that patient is deemed stable
Measure: The number of eligible patients for whom viral load was monitored every 4 months

Appropriate management for patients unstable on ARV therapy

Eligibility: Viral load has increased by more than 1 log and absolute value is over 1000; or CD4 has dropped by 50% since the last 4-month review period; or opportunistic infection in the last 4-month review period (new or recurrent); or patient deemed unstable by physician
Measure: One of the following four management options is documented in the medical record in every 4-month period the patient is considered unstable:

• Regimen was changed and viral load assay performed within 8 weeks of decision
• Justification provided for not changing therapy (intercurrent illness, recent vaccination, adherence intervention documented, viral load reordered, patient prefers not to change medication, provider documents that patient is clinically/immunologically stable, resistance testing ordered, other) and viral load assay performed within 8 weeks of decision
• Documentation that patient decides not to take medication and viral load assay performed within 4 months
• Decision made to discontinue therapy and clinical follow-up plan noted in record within 4 months

Appropriate management for end-stage patients or patients with no other therapeutic options

Eligibility: Patient meets unstable criteria outlined above, but clinician documents that patient has no other therapeutic options available, or patient documented to be end stage within last 12 months
Measure: The number of eligible patients for whom a follow-up clinic visit is recorded every 4 months
Treatment Adherence Eligibility: All patients prescribed ARV therapy
Measure: Adherence is measured and described quantitatively at least once every 4 months

B. Other Performance Indicators

Viral Load Measurement

Eligibility: All patients, with the exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during a 4-month review period
Measure: The number of patients for whom viral load test was performed

HIV Specialist Care

Eligibility: All patients, with the exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during a 4-month review period
Measure: The number of patients who are seen by an HIV Specialist

Mental Health Assessment