QUALITY OF CARE

Organizational Quality Assessment Tool

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This assessment, which is included in an appendix in the booklet shown at the left, identifies all of the important elements associated with a sustainable quality management program.

Purpose of the Organizational Assessment

Sustained improvement activities require attention to the organizational quality management program (QMP), in which structures, processes, and functions support measurement and improvement activities. Development, implementation, and spread of sustainable quality improvement (QI) throughout an HIV program require an organizational commitment to quality management. 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.

This assessment identifies all of the important elements associated with a sustainable QMP. Scores from 0–5 are defined to identify gaps in the QMP and to set program priorities for improvement. The scoring structure measures program performance in specific domains along the spectrum of improvement implementation. When assigning a score of 0–5 for individual components, the whole number that most accurately reflects organizational achievement in that area should be selected. If there is any uncertainty in assessing whether performance is closer to the statement in the next higher or next lower range, the lower score should be chosen. Scoring is designed so that all items in a score must be satisfied to reach any one score for a component. Applied annually, this assessment will help a program evaluate its progress and guide the development of goals and objectives.

The OA is implemented in two ways: 1) by an expert QI consultant or 2) as a selfevaluation. The results ideally will be used to develop a workplan for each element with specific action steps and timelines guiding the planning process to focus on priorities, setting direction, and ensuring that resources are allocated for the QMP. Whether the OA is performed by a QI consultant 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. Engagement of program leadership and staff is critical to ensure buy-in across the program and is essential for translating results into improvement practice

Purpose

Download PDF
Download PDF

This assessment, which is included in an appendix in the booklet shown at the left, identifies all of the important elements associated with a sustainable quality management program.

Purpose of the Organizational Assessment

Sustained improvement activities require attention to the organizational quality management program (QMP), in which structures, processes, and functions support measurement and improvement activities. Development, implementation, and spread of sustainable quality improvement (QI) throughout an HIV program require an organizational commitment to quality management. 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.

This assessment identifies all of the important elements associated with a sustainable QMP. Scores from 0–5 are defined to identify gaps in the QMP and to set program priorities for improvement. The scoring structure measures program performance in specific domains along the spectrum of improvement implementation. When assigning a score of 0–5 for individual components, the whole number that most accurately reflects organizational achievement in that area should be selected. If there is any uncertainty in assessing whether performance is closer to the statement in the next higher or next lower range, the lower score should be chosen. Scoring is designed so that all items in a score must be satisfied to reach any one score for a component. Applied annually, this assessment will help a program evaluate its progress and guide the development of goals and objectives.

The OA is implemented in two ways: 1) by an expert QI consultant or 2) as a self-evaluation. The results ideally will be used to develop a workplan for each element with specific action steps and timelines guiding the planning process to focus on priorities, setting direction, and ensuring that resources are allocated for the QMP. Whether the OA is performed by a QI consultant 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. Engagement of program leadership and staff is critical to ensure buy-in across the program and is essential for translating results into improvement practice.

Quality Management

GOAL: To assess the HIV program infrastructure to support a systematic process with identified leadership, accountability, and dedicated resources.

Three components form the backbone of a strong, sustainable quality program: leadership, quality planning, and a quality committee.

1. Leadership: Senior leadership personnel are defined by each organization since titles and roles vary among organizations. Clinical HIV programs should include a clinical leader (medical director, senior nurse) and an administrative leader (program coordinator, clinic manager, administrative director). Larger programs may include additional leadership positions. There may be other informal leaders in the organization who support quality activities, but these are not included in this section.

Leaders establish a unity of purpose and direction for the organization and work to engage all personnel, consumers, and external stakeholders in meeting organizational goals and objectives. This includes providing motivation that promotes shared responsibility and accountability with a focus on teamwork and individual performance. HIV program leaders should prioritize quality goals and improvement projects for the year and should establish accountability for performance at all organizational levels. The benefits of strong leadership include the clear communication of goals and objectives, wherein evaluation, alignment, and implementation of activities are fully integrated.

Evidence of leadership support and engagement includes the establishment of clear goals and objectives, the communication of program/organizational vision, the creation and sustainment of shared values, and the provision of resources for implementation.

2. Quality Committee: A quality committee drives implementation of the quality plan and provides high-level comprehensive oversight of the quality program. This involves reviewing performance measures, developing workplans, chartering project teams, and overseeing progress. Teams should be multidisciplinary and include a consumer when feasible. Consumer representation on the committee should be part of a formal engagement process wherein consumer feedback is solicited and integrated into the decision-making process. The committee should have regularly scheduled meetings, meeting notes to be distributed throughout the program, and a committee chair or chairs.

3. Quality Plan: Quality improvement planning occurs with initial program implementation and annually thereafter. A quality management plan documents programmatic structure and annual quality team goals. The quality plan should serve as a road map to guide improvement efforts and should include a corresponding workplan to track activities, monitor progress, and signify achievement of milestones.

A.1. To what extent does senior leadership create an environment that supports a focus on improving the quality of HIV care? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ Senior leaders are not visibly engaged in the quality of care program.
Planning and initiation 1

Leaders:

_ are not fully involved in improvement efforts, quality meetings, or providing resources for QI activities.

_ are primarily focused on meeting external requirements and supporting compliance with regulations.

_ inconsistently use data to identify opportunities for improvement.

Beginning implementation 2

Leaders:

_ are not engaged optimally. are engaged in quality of care with focus on use of data to identify opportunities for improvement.

_ are somewhat involved in improvement efforts.

_are somewhat involved in quality meetings.

_ support some resources for QI activities.

Implementation 3

Leaders:
_ provide routine leadership to support the QMP.

_ provide routine and consistent allocation of staff or staff time for QI (depending on facility size).

_ are actively engaged in QI planning and evaluation.

_ actively manage/lead quality meetings.

_ clearly communicate quality goals and objectives to all staff.

_ recognize and support staff involved in QI.

_ routinely review performance measures and patient outcomes to inform program priorities and data use for improvement.

_ are attentive to national healthcare trends

Progress toward systematic approach to quality 4

Leaders:

_ support development of a culture of QI across the program, including provision of resources for staff participation in QI learning opportunities, seminars, professional conferences, QI storyboards for distribution, drafting of scholarship, etc.

_ support prioritization of quality goals based on data and address critical areas of care in coordination with broader strategic goals for HIV care.

_ promote patient-centered care and consumer involvement through the QMP.

_ are routinely engaged in QI planning and evaluation.

_ routinely provide input and feedback to QI teams.

Full systematic approach to quality management in place 5

Leaders:

_ are actively engaged in the implementation and shaping of a culture of QI across the program, including provision of resources for staff participation in QI learning opportunities, seminars, professional conferences, QI storyboards for distribution, drafting of scholarship, etc.

_ encourage open communication through routine team meetings and dedicated time for staff feedback.

_ are routinely and consistently engaged in QI planning and evaluation.

_ routinely and consistently provide input and feedback to QI teams.

_ encourage staff innovation through QI awards or incentives.

_ directly link QI activities back to institutional strategic plans and initiatives.

A.2. To what extent does the HIV program have an effective quality committee to oversee, guide, assess, and improve the quality of HIV services? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ A quality committee has not yet been developed or formalized or is not currently meeting regularly to provide effective oversight for the quality program.
Planning and initiation 1

The quality committee:

_ may review data triggered by an event or problem, or generated by donor or regulatory urging.

_ has minimally integrated quality activities into other existing meetings

Beginning implementation 2

The quality committee:

_ has plans to hold regular meetings, but meetings may not occur regularly and/or do not focus on performance data.

_ has been formalized, representing most institutional disciplines.

_ has identified roles and responsibilities for participating individuals.

Implementation 3

The quality committee:

_ is formally established and led by a program director, medical director, or senior clinician.

_ has implemented a structured process to review data for improvement.

_ has defined roles and responsibilities as codified in the quality plan.

_ reviews performance data regularly, including staff and consumer satisfaction information, if available.

_ discusses QI progress and redirects teams as appropriate.

Progress toward systematic approach to quality 4

The quality committee:

_ is formally established and led by a program director, medical director, or senior clinician specifically tasked with active oversight of the work of the quality program with established annual meeting dates.

_ represents all disciplines. has established a performance review process to regularly evaluate clinical measures and respond to results as appropriate, including staff and consumer satisfaction information.

_ communicates with nonmembers through distribution of minutes and discussion in regular staff meetings.

_ actively utilizes a workplan to closely monitor progress of quality activities and team projects.

_ provides progress reports to the organization-wide quality program.

Full systematic approach to quality management in place 5

The quality committee:

_ is a formal entity led by a senior clinician or administrator and, where appropriate, is linked to organizational quality committees through common members.

_ has established a systematic performance review process, including clinical measures, consumer satisfaction, and operational measures to identify annual goals.

_ is responsive to changes in treatment guidelines and external/national priorities (NAHS, HAB, CMS) and considers these in the development of indicators and choosing improvement initiatives.

_ has fully engaged senior leadership who lead discussions during committee meetings.

_ effectively communicates activities, annual goals, performance results, and progress on improvement initiatives to all stakeholders, including staff, consumers, and board members.

 

Workforce Engagement in the HIV Quality 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 retrain – ing of staff can be accomplished through formal sessions provided internally by the organization or externally through legitimate training resources such as the National Quality Center (NQC). 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 progress along the con – tinuum 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 _ Staff (clinical and nonclinical) are not routinely engaged in QI activities and are not provided training to enhance skills, knowledge, theory or methodology, and are not encouraged to identify opportunities for improvement or to develop effective solutions.
Planning and initiation 1

Engagement of core staff (clinical and nonclinical) in QI:

_ 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 (clinical and nonclinical) in QI:

_ 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 (clinical and nonclinical) in QI includes:

_ attendance in at least one training session about QI methodology, and staff members are generally aware of QI activities (quality plan, priorities, etc.).

_ involvement in QI projects, project selection, and participation in a QI committee.

_ QI project development, wherein projects are discussed and reviewed during staff meetings.

_ defined roles and responsibilities related to QI such that 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 (clinical and nonclinical) in QI 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.

_ a 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 (clinical and nonclinical) in QI 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 shape 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 QMPs.

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 wherein 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.

 

Measurement, Analysis, and Use of Data to Improve Program Performance

GOAL: To assess how the HIV program uses data and information to identify opportunities for improvement and develops measures to evaluate the success of change initiatives, to align initiatives, and to monitor program status, while ensuring that accurate, timely data and information are available to stakeholders throughout the organization to drive effective decision-making.

The Measurement, Analysis, and Use of Data section assesses how the program selects, gathers, analyzes, and uses data to improve performance. This includes how leaders conduct performance reviews to ensure that actions are taken, when appropriate, to achieve program goals.

C.1. To what extent does the HIV program routinely measure performance and use data for improvement? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ Performance measures have not been identified
Planning and initiation 1

Performance measures:

_ have been identified to evaluate some components of the program, but do not cover all significant aspects of service delivery.

_ are defined and used by personnel at some, but not all, units or sites.

Performance data:

_ collection is planned pending initiation.

Beginning implementation 2

Performance measures:

_ are externally defined and used by personnel at all applicable site

Performance data:

_ validation, analysis, and interpretation of results on measures are in early stages of development and use.

_ results are occasionally shared with staff and patients.

Implementation 3

Performance measures:

_ are externally defined or required (e.g., HAB, HIVQUAL), with the intention of meeting external regulatory requirements and the needs of stakeholders, including patients.

_ are defined and consistently used by personnel at all applicable sites.

Performance data:

_ are tracked, analyzed, and reviewed with the frequency required to identify areas in need of improvement, and a structured review process is used regularly by the leadership to identify and prioritize improvement needs and to initiate action plans to ensure that goals are achieved.

_ are collected by staff with working knowledge of indicator definitions and their application.

_ results and associated measures are routinely shared with staff, and their input is elicited to make improvements.

Progress toward systematic approach to quality 4

Performance measures:

_ are externally defined or required (e.g., HAB, HIVQUAL) and tied to annual organizational goals, with the intention of meeting external regulatory requirements, the needs of stake – holders and patients, and the goal of alignment with current evidence in the diagnosis and treatment of HIV.

_ reflect priorities of clinic staff and patients, in consideration of local issues.

Performance data:

_ results and associated measures are frequently shared with staff to elicit their input and engage them in improvement processes aligned with organizational goals.

 

Full systematic approach to quality management in place 5

Performance measures:

_ are selected using organizational annual goals, with the intention of meeting external regulatory requirements as well as the needs of stakeholders and patients, and the goal of alignment with current evidence in the diagnosis and treatment of HIV.

_ reflect priorities of clinic staff and patients, in consideration of local issues.

_ are defined for each program component and actively used to drive improvement activities.

_ are evaluated regularly to ensure that the program is able to respond effectively and quickly to internal and external changes.

Performance data:

_ are visible or easily accessible to ensure data reporting transparency throughout the clinic.

_ are arrayed in formats that enable accurate interpretation, such as run charts and/or control charts.

_ results and associated measures are systematically shared with all stakeholders, including staff, patients, and board members, to elicit their input and engage them in improvement processes aligned with organizational goals.

Quality Improvement Initiatives

GOAL: To evaluate how the HIV program applies robust process improvement methodology* to achieve program goals and maintain high levels of performance over long periods of time.

The Quality Improvement Initiatives section examines how leadership and workforce use these methods and tools to conduct improvement initiatives with emphasis on identifying the exact causes of problems and designing effective solutions, determining program-specific best practices, and sustaining improvement over long periods of time. In high-reliability organizations, robust process improvement methodology is routinely utilized for all identified problems and improvement opportunities to ensure consistency of approach by all staff members.

*Robust process improvement includes reliably measuring the magnitude of a problem, identifying the root causes of the problem, measuring the importance of each cause, finding solutions for the most important causes, proving the effectiveness of those solutions, and deploying programs to ensure sustained improvements over time.

D.1. To what extent does the HIV program identify and conduct quality improvement initiatives using robust process improvement methodology to ensure high levels of performance over long periods of time? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ Formal quality improvement projects have not yet been initiated in the program.
Planning and initiation 1

QI initiatives:

_ do not include assessment of organizational performance or system-level analysis of data, are not team based, and do not use specific tools or methodology.

_ focus on individual cases only.

_ use reviews primarily for inspection.

Beginning implementation 2

QI initiatives:

_ are prioritized by the quality committee based on program goals, objectives, and analysis of performance measurement data.

_ involve team leaders and team members who are assigned by the quality committee or other leadership.

_ are beginning to use specific tools or methodology to understand causes and make effective changes.

Implementation 3

QI initiatives:

_ are ongoing based on analysis of performance data and other program information, including external reviews and assessments.

_ focus on processes of care in which QI methodology is routinely utilized.

_ are regularly documented and provided to the quality committee. involve staff on QI teams, and cross-departmental/cross-functional teams

_ are developed depending on specific project needs.

Progress toward systematic approach to quality 4

QI initiatives:

_ reflect input from staff through a transparent process.

_ routinely and consistently reinforce and promote a culture of QI throughout the program through shared accountability and responsibility of identified improvement priorities.

_ are supported with appropriate resources to achieve effective and sustainable results.

_ involve support of data collection with results routinely reported to QI project teams.

Full systematic approach to quality management in place 5

QI initiatives:

_ are ongoing in every service category. correspond with a structured process for prioritization based on analysis of performance data and other factors.

_ are implemented by project teams, and physicians and staff can identify an improvement opportunity at any point in time and suggest a QI team be initiated.

_ consistently and routinely utilize robust process improvement and multidisciplinary teams to identify actual causes of variation and apply effective sustainable solutions.

_ are guided by a team leader or sponsor and include all relevant staff, depending on specific project needs.

_ are regularly communicated to the quality committee, staff, and patients. routinely involve consumers on QI project teams.

_ are presented in storyboard context or other formats and reported to the larger organization and/or placed in public areas for staff and patients (if relevant).

_ involve recognition of successful teamwork by senior leadership. are supported by development of sustainability plans

Consumer Involvement

GOAL: To assess the extent to which consumer involvement is formally integrated into the QMP.

Consumer involvement encompasses the diversity of individuals using HIV programmatic services and can be achieved in multiple ways, including: solicitation of consumer perspectives through focus groups, key informant interviews, and satisfaction surveys; a formal consumer advisory board that is actively engaged in improvement work; consumers as members of program committees and boards; conducting consumer needs assessments; and including consumers in specific QI initiatives. Ideally, consumers should have a venue to identify improvement concerns and should be integrated into the process to find solutions and develop improvement strategies. Overall, consumers are considered valued members of the program so that consumer perspectives are solicited, information is used for performance improvement, and feedback is provided to consumers. 

E.1. To what extent are consumers effectively engaged and involved in the HIV 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 currently no process to involve consumers in HIV quality management.
Planning and initiation 1

Consumer involvement:

_ includes no formal process for ongoing, systematic participation in quality management program activities.

_ is occasionally addressed by soliciting consumer feedback.

Beginning implementation 2

Consumer involvement:

_ is addressed by soliciting consumer feedback, with the development of a formal process for ongoing, systematic participation in quality management program activities.

Implementation 3

Consumer involvement:

_ includes engagement with consumers to solicit perspectives and experiences related to quality of care.

_ is part of HIV quality management program activities through a formal consumer advisory committee, satisfaction surveys, interviews, focus groups and/or consumer training/ skills-building; however, the extent to which consumers participate in quality management program activities is not documented or assessed

Progress toward systematic approach to quality 4

Consumer involvement:

_ is part of a formal process for consumers to participate in HIV quality management program activities, including a consumer advisory committee, surveys, interviews, focus groups and/or consumer training/skills building.

_ in improvement activities includes three or more of the following:

  • sharing performance data and discussing quality during consumer advisory board meetings
  • membership on the internal quality management team or committee
  • training on quality management principles and methodologies
  • engagement to make recommendations based on performance data results
  • increasing documentation of recommendations by consumers to implement quality improvement projects

_ information gathered through the above noted activities is documented and used to improve the quality of care.

Full systematic approach to quality management in place 5

Consumer involvement:

_ contributions and impact on quality are reviewed with consumers.

_ is part of a formal, well-documented process for consumers to participate in HIV quality management program activities, including a consumer advisory committee with regular meetings, consumer surveys, interviews, focus groups, and consumer training/skills-building.

_ in quality improvement activities includes four or more of the items bulleted in E.1., level 4.

_ information gathered through the above noted activities is documented, assessed, and used to drive QI projects and establish priorities for improvement.

_ includes work with program staff to review changes made based on recommendations, with opportunities to offer refinements for improvements; information is gathered in this process and used to improve the quality of care.

_ involves, at minimum, an annual review by the quality management team/committee of the successes and challenges of consumer involvement in quality management program activities in order to foster and enhance collaboration between consumers and providers engaged in quality improvement.

Quality Program Evaluation

GOAL: To assess how the program evaluates the extent to which it is meeting the identified program goals related to quality improvement planning, priorities, and implementation.

Quality program evaluation can occur at any point during the cycle of quality activities, but it should occur annually at a minimum. The process of evaluation should be linked closely to the quality plan goals in order to assess what worked and what did not, to determine ongoing improvement needs, and to facilitate planning for the upcoming year. The evaluation examines the methodology, infrastructure, and processes, and assesses whether or not these led to expected improvements and desired outcomes. At a minimum, the evaluation should assess access to data to drive improvements, success of QI project teams, and the effectiveness of the quality structure. Where appropriate, external evaluations and assessments should be utilized in partnership with the internal evaluation. The evaluation is most effectively performed by program leadership and the program’s quality committee, optimally with some degree of consumer involvement

F.1. Is a process in place to evaluate the HIV program’s infrastructure, activities, processes, and systems to ensure attainment of quality goals, objectives, and outcomes?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ No formal process is established to evaluate the quality program.
Planning and initiation 1

Quality program evaluation:

_ to assess program processes and systems is exclusively external.

Beginning implementation 2

Quality program evaluation:

_ is part of a formal process and is integrated into annual quality management plan development

Implementation 3

Quality program evaluation:

_ occurs annually, is conducted by the quality committee, and includes QM plan and workplan updates and revisions.

_ involves annual (at minimum) revision of quality goals and objectives to reflect current improvement needs.

_ results are used to plan for future quality efforts.

_ includes a summary of improvements and performance measurement trends to document and assess the success of QI projects.

_ results, noted above, are shared with consumers and other key stakeholders

Progress toward systematic approach to quality 4

Quality program evaluation:

_ findings are integrated into the annual quality plan and used to develop and revise program priorities.

_ is reviewed during quality committee meetings to assess progress toward planning goals and objectives.

_ includes review of performance data, which is used to inform decisions about potential changes to measures.

_ is used to determine new performance measures based on new priorities.

_ includes analysis of QI interventions to inform changes in program policies and procedures to support sustainability.

Full systematic approach to quality management in place 5

Quality program evaluation:

_ findings are integrated into routine program activities as part of a systematic process for assessing quality activities, outcomes, and progress toward goals; data and information are provided regularly to the quality committee.

_ is used by the quality committee to regularly assess the success of QI project work, successful interventions, and other markers of improved care.

_ includes data reflecting improvement initiatives and is presented to ensure comprehensive analysis of all quality activities.

_ uses a detailed assessment process, the results of which are utilized to revise and update the annual quality plan, adjust the HIV program priorities, and identify gaps in the program.

_ includes an analysis of progress toward goals, objectives, QI program successes, and accomplishments.

_ describes performance measurement trends, which are used to inform future quality efforts.

_ communicates evidence that QI efforts informed through this process resulted in measureable improvement.

Achievement of Outcomes

GOAL: To assess HIV program capability for achieving excellent results and outcomes in areas that are central to providing high-quality HIV care.

In order to determine whether a program is achieving excellence in HIV care, a system for monitoring and assessing clinical outcomes should be in place. This system should include: analysis of an appropriate set of measures; trending results over time; stratification of data by high-prevalence populations (see G.2.); and comparison of results to a larger aggregate data set* used for programmatic target setting. A set of appropriate measures may be externally developed (i.e., HAB, HIVQUAL) and/or internally developed based on program goals. Viral load suppression and retention in care are two essential measures of outcome that should be incorporated into the program’s set of clinical measures.

*Possible data sets for comparison include HIVQUAL, HAB, In+Care Campaign, regional groups, RSR, VA, Kaiser, HIVRAD

G.1. To what extent does the HIV program monitor patient outcomes and utilize data to improve patient care?Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ No clinical performance results are routinely reviewed or used to guide improvement activities.
Planning and initiation 1

Data:

_ for some measures are routinely reviewed and used to guide improvement activities.

_ trends for some measures are reported to determine improvement over time.

Beginning implementation 2

Data:

_ results for most measures are routinely reviewed and used to guide improvement activities.

_ trends for most measures are reported, and many show improving trends over time.

Implementation 3

Data:

_ results for all measures are routinely reviewed and used to guide improvement activities, including viral load suppression and retention in care.

_ trends for all measures are reported, and many show improving trends over time.

_ results are compared to a larger aggregate data set for at least two outcome measures: viral load suppression and retention in care.

_ comparison to larger aggregate data sets is used to set programmatic targets.

Progress toward systematic approach to quality 4

Data:

_ comparison to larger aggregate data sets is used to set programmatic targets, and targets are met for at least 50 percent of measures.

_ results for viral load suppression and retention in care scores are equal to or greater than the 75th percentile of the comparative data set

Full systematic approach to quality management in place 5

Data:

_ trends are reported for all measures, and most show sustained improvement over time in areas of importance aligned with organizational goals.

_ comparison to larger aggregate data sets is used to set programmatic targets, and targets are met for at least 75 percent of measures.

_ results for viral load suppression and retention in care scores are above the 75th percentile of the comparative data set.

Reduction in Disparities in HIV Care

GOAL:  To ensure that all patients receive the same level of quality services and resulting health outcomes, regardless of their exposure category, race/ethnicity, gender, age, or economic status.

This section assesses the program’s ability to ensure that all patients, regardless of their exposure category, race/ethnicity, gender, age, or economic status, receive the same level of quality care. In order to achieve equity in quality and outcomes for all patients, a system for consistent review of data stratified by these factors and evidence of actions taken for any disparities identified would be needed.

G.2. To what extent does the HIV program measure disparities in care and patient outcomes and use performance data to improve care to eliminate or mitigate discernible disparities? Each score requires completion of all items in that level and all lower levels (except any items in level 0).
Getting started 0 _ No clinical performance results are routinely reviewed or used to address disparities.
Planning and initiation 1

Performance measures/data:

_ are stratified for analysis of disparities by gender, age, socioeconomic status, risk factor, geography, etc.

Beginning implementation 2

Performance measures/data:

_ are used to identify disparities.

_ are used to plan improvement strategies.

Implementation 3

Performance measures/data:

_ are used to develop and implement general improvement strategies

Progress toward systematic approach to quality 4

Performance measures/data:

_ are used to develop and implement general and targeted improvement

_ strategies based on data analysis. demonstrate some evidence of improvement of outcomes for identified disparities.

Full systematic approach to quality management in place 5

Performance measures/data:

_ demonstrate sustained evidence of improvement of outcomes for identified disparities

Summary of Results

What are the major findings from the Organizational Assessment?

Please number and link all findings with key recommendations and suggestions. Major findings should address all components with a score below 3.

What are the key recommendations and suggestions? What specific areas should be improved? What are specific improvement goals for the upcoming year?

Please include associated time frame for each recommendation and improvement goal. Recommendations and areas in need of improvement should address all components with a score below 3