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2. Workshop Presenters . Lanet Williams, RN, MSN, PHNManager-Quality Management-Office of AIDS Programs and Policy, Los Angeles EMAJacqueline Rurangirwa, MPHEpidemiologist-Planning
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1. 1 Implementing Agency-wide Quality Improvement Plans, Los Angeles County Experience
2. 2 Workshop Presenters Lanet Williams, RN, MSN, PHN
Manager-Quality Management-Office of AIDS Programs and Policy, Los Angeles EMA
Jacqueline Rurangirwa, MPH
Epidemiologist-Planning & Research-Office of AIDS Programs and Policy, Los Angeles EMA
Moderator: Marcy Fenton
3. 3 Learning Objectives
By the end of this session, participants will be able to:
Identify the advantages and disadvantages of developing an agency-wide quality improvement plan that encompasses all HIV/AIDS related services
Identify practical problems or gaps in implementation of a quality improvement plan using indicators and data analysis in evaluating standards of care
4. 4 Learning Objectives-Continued
Identify ways to continuously improve quality in data collection and using data from required indicators in evaluating standards of care.
5. 5 QI plans are evaluated through a review process and through contract monitoring
6. 6 Los Angeles County Contract Monitoring
Ensures that agencies are engaged in QI
Develop quality Improvement plan
Establish quality management committee
Meet regularly
Collect measures/indicators
Develop quality improvement activities
7. 7 Contracting
Agencies are contracted to provide a high level of service
Service requirements are based on
Established practice guidelines
Industry standards
Local, state and federal regulations
Monitoring aims to support the necessary organizational development through
Technical assistance
Capacity building activities
8. 8 Contracting-Continued
Monthly reports and site visits
Determine if agencies adhered to fiscal and contractual agreements
9. 9 Objective #1
Identify the advantages and disadvantages of developing an agency-wide quality improvement plan that encompasses all HIV/AIDS related services
10. 10 Historical Perspective
Historically, QI plans were developed per service category; hence an agency would potentially have several different QI plans depending on the number of services provided.
11. 11 Contract Language Year 12
Contents of QI Plan:
QM Committee
Develop, review, revise
Develop plan of corrective action for identified deficiencies
Documentation of agenda, minutes, sign-in sheets, etc.
12. 12 Contract Language Year 12-cont. Written Policies and Procedures
Based on essential program activities
Community and professional standards of care specific to the contract
Describe the process for reviewing and revising policy and procedures
Client Feedback
Mechanism for obtaining feedback from program participants regarding program effectiveness, accessibility, and client satisfaction
Feedback collected and feedback used by QM committee to make improvements to the program
13. 13 Contract Language Year 12-cont. Program Staff
Describe process for developing, training, and monitoring staff
Describe methods used to monitor staff performance
Describe minimum staff qualifications
Measurable Service Quality indicators
Quality indicators developed based on activities described in services to be provided
Establishing a minimum standard for each indicator
QM Plan Implementation Process
14. 14 Contract Language Year 12-cont.
Mid/Year end summary Reports
Mid-year report-document program performance, plan of corrective action, areas of concern
Year-end report-Actions addressing findings in mid-year report.
Include overall performance both mid and year end.
15. 15 QI Plans Review Process
Submission requirement-according to contract language
Assessed and evaluated by staff via evaluation tool
Denials-Technical assistance provided
Time frame for corrective action
Approvals-Letters sent Noting approval
16. 16 QI Plan Outcomes Year 12
17. 17 HIV-Prevention
Although not a HRSA Requirement, the overall goal of Los Angeles County is to also ensure HIV Prevention Providers have a system in place to:
Evaluate
Monitor
Improve Quality Service
QM was instrumental in the development and implementation of QM plans for all funded Prevention Providers
18. 18 QI Plan Outcomes-2001/2002 Prevention:
19. 19 Next Steps
Provider Technical Assistance in Formal Setting
Provider Training
Staff Training
20. 20 Technical Assistance Year 12
Provider Training-To prepare for Year 13
Overview of Contractual Requirements
HRSA QM requirements
Update on QM Language
Developing QM Plans
For Contract Year-12 OAPP’s Quality Management staff participated in (seven) Mandatory Training’s for Care Service Providers in: HRSA Quality Management Requirements, up-date on Contract Language Changes, and Technical Assistance for developing/modifying (QM) plans.
· Sixty-one Care Service Providers (Executive Director) was notified by letter to request their agency’s participation at a mandatory meeting for HIV/AIDS Care Service contractors. This meeting provide an overview of contractual requirements for their upcoming contract term.
· OAPP’s Quality Management staff sponsored (technical assistance) a Mandatory Quality Management Workshop for OAPP’s Program Managers and staff in both Care Services/ Prevention Services. There were seven workshops with forty-one participants in attendance. This workshop provided an overview of “What is Quality Management”. HRSA Requirements/Expectations, Three –Fold Purpose, QM Staff Responsibilities and Comprehensive Program Site Visit Findings. Session ll. the (QM) staff provided hands on interactive exercise for (QM) contractual requirement and components, monitoring tool for thirty-two-service category, and measurable process and outcome indicators.
For Contract Year-12 OAPP’s Quality Management staff participated in (seven) Mandatory Training’s for Care Service Providers in: HRSA Quality Management Requirements, up-date on Contract Language Changes, and Technical Assistance for developing/modifying (QM) plans.
· Sixty-one Care Service Providers (Executive Director) was notified by letter to request their agency’s participation at a mandatory meeting for HIV/AIDS Care Service contractors. This meeting provide an overview of contractual requirements for their upcoming contract term.
· OAPP’s Quality Management staff sponsored (technical assistance) a Mandatory Quality Management Workshop for OAPP’s Program Managers and staff in both Care Services/ Prevention Services. There were seven workshops with forty-one participants in attendance. This workshop provided an overview of “What is Quality Management”. HRSA Requirements/Expectations, Three –Fold Purpose, QM Staff Responsibilities and Comprehensive Program Site Visit Findings. Session ll. the (QM) staff provided hands on interactive exercise for (QM) contractual requirement and components, monitoring tool for thirty-two-service category, and measurable process and outcome indicators.
21. 21 Technical Assistance Year 12
Staff Training-Care and Prevention
Session I
Overview of Quality Management-QI Plans
HRSA Requirement/Expectations
Staff Responsibilities
22. 22 Technical Assistance Year 12-Cont.
Session II
Interactive
Monitoring tools reviewed
Discussed measurable process and outcome indicators
23. 23 Contract Language Year 13 Contents of QI Plan: Unchanged
QM Committee
Written Policy and Procedures
Client Feedback
Program Staff
Measurable Process and Outcome indicators
QI Plan Implementation Process
Mid/Year end summary Reports
24. 24 How did we assess the impact of technical assistance provided In year 12 to staff and providers for year 13 contracts?
25. 25 Through Review of the QI Plan and Contract Monitoringfor Year 13
26. 26 QI Plan Results Year 13 Outcomes
27. 27 QM Plan Results-2002/2003 Prevention
28. 28 Lessons Learned Assessed Implementation of QI Plans After TA
Findings:
Increase Number of plans submitted for Care
More service categories
Low percentages
29. 29 Lessons Learned cont.
Decreased number of plans submitted for Prevention
Less service categories
Higher percentages
Look at absolute numbers instead of percentages
30. 30 QI Plan Results Year 14 Outcomes
31. 31 Lessons Learned Year 14 Care
Improved outcomes from Year 13
32. 32 Next Steps
Thoughts to change language Year 15
Want to incorporate all HIV/AIDS Services in one contract
Include indicators
33. 33 New Contract Requirements Year 15
Agencies are requested to develop one plan that encompasses all HIV/AIDS related services with selected indicators to be used in evaluating standards of care.
34. 34 Contract Language Year 15 Contents of QI Plan:
Objectives
QM committee
Selection Of a QM Approach
QM Program Content
Client Feedback
Client Grievances
Incident Reporting
Random Chart Audits
35. 35 Contract Language Year 15
Objectives
Goals and objectives that reflect the program’s mission, vision, and values
QM committee
Describe the purpose, its composition, meeting frequency
Required documentation-(i.e., minutes, agenda, sign-in sheets, etc.)
36. 36 Contract Language Year 15
Selection Of a QM Approach
Describe approach used such as; PDSA, Chronic Care, and JCAHO
QM Program Content
Outcome Indicators
Data Collection
Data Analysis
37. 37 Contract Language Year 15
Client Feedback
Describe mechanism for obtaining ongoing feedback regarding accessibility, and appropriateness of care, and degree to which service meet clients needs.
Aggregated data reported to committee for continuous quality improvement
38. 38 Contract Language Year 15
Client Grievances
Establish P & P for resolving complaints
Track, trend, and report to QM committee for improvement in services
39. 39 Contract Language Year 15
Incident Reporting
Reports made to the office as well as the appropriate regulatory authority under both Federal and State guidelines
Random Chart Audits
10% or 30 chart whichever is less
Results reported and discussed in QM committee
40. 40 QM Plan Results Year 15 Outcomes:
41. 41 Lessons Learned Year 15 Plans not inclusive of all services
Contract monitoring revealed decreased coordination between program staff
Client feedback and service information not being feedback to QM/QI Committee
Providers not prepared to implement one QI plan encompassing all services
Not punitive
Provided additional TA
42. 42 QI Results Year 12-15 Analysis
43. 43 Advantages of Having One Agency QI Plan
Less cumbersome for the provider and Los Angeles County
Continuity of care is maintained
Coordinated effort between program staff
Strengthen QM/QI committee through collaboration and feedback for all services provided
Helps facilitate a process for CQI
44. 44 Disadvantages of Having One Agency QI Plan
Time consuming
Staff knowledge and skill regarding QI/QM/CQI
Collaboration across all programs may be challenging
Adapting to changes in the contract
45. 45 Next Steps Year 16
Look at year 16 QI Plans
Anticipate an increase in the number of approved QI plans
Additional TA/Provider Training in formal setting as needed
Schedule periodic training twice a year
46. 46 Objective #2
Identify practical problems or gaps in implementation of a quality improvement plans using indicators and data analysis in evaluating standards of care
47. 47 Quality Improvement (QI) Defined
Concentrates on identifying areas to be improved instead of just looking to see if a certain standard is met
Developing steps to bring about that improvement
Following-up to ensure the improvement is sustained
48. 48 Quality Improvement Plan LA County requires each contractor
Develop QM plan
New contracts states that an agency should have one agency-wide plan encompassing all HIV/AIDS care and prevention services
LA County’s QM staff monitors the agency’s implementation of the QM plan
New contracts specify indicators
49. 49 So how did we began looking at QI plans and indicators to assess and evaluate the Standards of Care with the focus on improving quality?
50. 50 Data Collection We began to;
Introduce providers to data collection methods
Encourage providers to identify indicators that are program specific
Encourage providers to collect data on pertinent indicators
Identify trends over time
Re-evaluate and improve quality in their programs
51. 51 Quality Improvement
Build quality capacity of care programs to conduct QI work
Establish standardized HIV performance
Service categories to focus on first
Medical Outpatient
Case Management
Treatment Adherence
Mental Health
52. 52 List of Other Services
Mental Health: Psychotherapy
Mental Health: Psychosocial
Psychosocial Case Management
Family Support Case Management
Transitional Case Management
Integrated (SPNS)
Child Care
53. 53 Other Services cont.
Nutrition
Permanency Planning
Legal Services
Peer Support
Oral Healthcare
Substance Abuse
Residential (Housing Assistance)
54. 54 Fall 2004
Reflected on past QI gains
Begin with Medical Outpatient and Case Management Services
Establish baseline
Evaluate available data
Contract monitoring surveys
Phone interviews with agencies
Monthly reports
55. 55 Medical Outpatient Data Year 13
56. 56 Type of Performance Indicators Collected for Year 13-MOP CD4 count tested at initial visit.
Viral load tested at initial visit
Syphilis screen done within the last quarter
GC tested within the past one year
Pap smear done within the past one year
PPD test done within the past one year
57. 57 CD4 Tested At Initial Visit, Year 13
58. 58 Viral Load Tested At Initial Visit, Year 13
59. 59 Syphilis Screen Done Within Last Quarter, Year 13
60. 60 PAP Done Within Last One Year, Year 13
61. 61 TB Skin Test (PPD) Done Within 1 Year, Year 13
62. 62 Lessons Learned in Yr 13 Implementation and Analysis
Labor intense methodology
Not efficient
Data collected for different purpose other than QI
Data not collected and documented in a standardized manner
Sample sizes (5-18 charts) too small
May not be a good representation of population
Results may be more positive than should be
63. 63 Year 14 – Expand Existing Database
CaseWatch, a single client data collection system to capture EMA-wide information
Designed to collect data for the Care Act Data Report
Adjust to be used for county-wide performance indicators
Yr 14 first year to use CaseWatch for QI analysis
64. 64 Type of Performance Indicators Collected From Casewatch System, Year 14
CD4 count collected every six months
Viral load test collected six months
Syphilis screen done within the past year
PAP screen done within the past year
TB skin test (PPD) done within the past year
65. 65
66. 66 Primary Medical Insurance Among CaseWatch Clients, Year 14
67. 67 CD4 Test Every 6 Months, Year 14
68. 68 Viral Load Test Every 6 Months, Year 14
69. 69 Syphilis Screening in the Past One Year, Year 14
70. 70 PAP Screening in the Past One Year, Year 14
71. 71 TB Skin Test (PPD) Screening in the Past One Year, Year 14 JJ
72. 72 Case Management Data Year 14
73. 73 Case Management-QM Components Achieved: Yr 14
74. 74 Implementation of QM Program: Case Management Yr 14
75. 75 Case Management: Yr 15 Preliminary data
21,079 clients utilized RWCA Title I services
6,051 (28.7%) clients utilized case management services
2,493 (41.2%) clients received a comprehensive assessment
76. 76 Case Management: Yr 15
77. 77 Case Management: Yr 15 Primary Medical Insurance
78. 78 Case Management: Yr 15
79. 79 Psychosocial Support Services: Yr 15 Preliminary data
21,079 clients utilized RWCA Title I services
611 (2.9%) clients utilized case management services
194 (31.8%) received a comprehensive assessment
Of the above 611 clients, 316 (51.7%) also utilized case management services
80. 80 Psychosocial Support Services: Yr 15
81. 81 Psychosocial Support Services: Yr 15 Primary Medical Insurance
82. 82 Psychosocial Support Services: Yr 15 Services accessed by Clients using psychosocial support services
83. 83 Lessons Learned Yr 15 From Preliminary Data Analysis
Casewatch only looks at quality indicators from providers perspective
Clients perspective not captured/quality of life questionnaire
Clear standardized definition of services under Case Management across all providers (OAPP)
Psychosocial Support
Psychosocial Support Family Services
84. 84 Next Steps
Electronic data validation
Verify that submitted data is correct
Unblind data once validation is achieved
85. 85 Next Steps
Achieve or exceed national benchmarks
Begin same process for other service categories
Produce annual report on each service category
86. 86 Objective #3
Identify ways to continuously improve quality in data collection and using data from required indicators in evaluating standards of care.
87. 87 Follow-up/Provider Training #1
Medical Outpatient QI workshop was held on 4/5/06
Reviewed the providers Quality Plan to ensure inclusion of all HIV/AIDS related services
Identified Practical Problems and gaps in the plan and ways to correct it
Identified QI goals from required indicators and ways to continue to improve quality by imputing accurate data
Provided data analysis from selected indicators
88. 88 QI Provider Training Outcome
MOP Provider Feedback-What they like best:
Information was very useful
Seeing the other stakeholders at the table
Knowing which way LA County is going
Clear and applicable to the real world
How to measure data to implement change
89. 89 QI Provider Training cont.
learning new ways to be more effective in planning
Interactive
Speakers provided concrete examples
90. 90 Follow-up/Provider Training #2 Case Management QI workshop was held on 8/2/06
Reviewed the providers Quality Plan to ensure inclusion of all HIV/AIDS related services
Identified practical problems and gaps in the plan and ways to correct it
Identified QI goals from required indicators and ways to continue to improve quality by imputing accurate data
Provided data analysis from selected indicators
91. 91 QI Provider Training Outcome CM Provider
Provider suggestions:
Would like quarterly trainings on QI
Would like to know who (agency) is performing at or above standard levels
New Managers prefer more trainings more often to help with QI Plan development and implementation
92. 92 Advantages of Implementing One QI Plan
Continuity of care can be established
Standards of care can be assessed using the data collected
Once data is validated, providers would have something to measure up to
93. 93 Disadvantages of Implementation of One QI Plan
Data validation for all services can be cumbersome
however when providers and staff embrace the importance of collecting data to improve services, it will no longer be a disadvantage.
Resource allocation to validate data
Time commitment
94. 94 Goal
To improve service and increase the overall quality of care and services to persons living with HIV/AIDS in Los Angeles, as well as for providers, and the community
95. 95 Questions
96.
Lanet Williams, RN, MSN, PHN
Manager, Quality Management
600 South Commonwealth Avenue, 2nd Floor
Los Angeles, California 90005-4001
Phone: 213/351-8263
E-mail: lanwilliams@ladhs.Org
Jacqueline Rurangirwa, MPH
Epidemiologist-Planning & Research
600 South Commonwealth Avenue, 2nd Floor
Los Angeles, California 90005-4001
Phone: 213/351-8354
E-mail: JRurangirwa @ladhs.Org
For Additional Information Note to presenters: You are responsible for sending an electronic copy of your presentation to the Public Affairs. The presentation will be posted on the OAPP website in PDF format.Note to presenters: You are responsible for sending an electronic copy of your presentation to the Public Affairs. The presentation will be posted on the OAPP website in PDF format.