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Quality Program Evaluation: Using Results for QI Action Planning. Nanette Brey Magnani, HIVQUAL Consultant NYSDOH AI Workshop December 19, 2008. Workshop Outcomes. Understand results of your program’s Organizational Quality Assessment.

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quality program evaluation using results for qi action planning

Quality Program Evaluation: Using Results for QIAction Planning

Nanette Brey Magnani, HIVQUAL Consultant

NYSDOH AI Workshop

December 19, 2008

workshop outcomes
Workshop Outcomes

Understand results of your program’s Organizational Quality Assessment.

Convert results of your Organizational Quality Assessment into a 2009 QI Action Plan for your organization.

Complete an Organizational Quality Assessment (OQA) of participants’ own program. (for those who do not have a completed OQA)

Gain a greater understanding of possible activities for improving QM Programs through participants’ exchange of their QI Action Plans.


9:30 Welcome and Introductions

9:45 Review Agenda and Workshop Outcomes.

Overview of Evaluation: Structure,

Process, Outcome, Action Planning

10:00 Using Results of Organizational

Quality Assessment Tool

(Participants bring documents: Results of

Org’l Quality Assessment Tool, QM

Plans, QI Workplans/Action Plan,

HIVQUAL results, QI Project results_

agenda contd
Agenda contd.

10:15 Small group work:

Task Group A: Convert results of OA into a

QI Action Plan for 2009

Task Group B: Understand and complete OA

for your HIV Quality Management Program

11:45 Report Back.

12:20 Wrap-up, Q & A, Evaluation

12:30 Adjourn.

a framework for qm program evaluation
A Framework for QM Program Evaluation
  • Structure: organizational structure, capacity
  • Process: activities
  • Outcome:
    • Intermediary: effectiveness of activities
    • Short-term and long-term benefits and changes for patients
change theory spread
Change Theory: Spread

Creating a New System


Hold Gains


  • The structure and process (activities) of QM Program can influence their effectiveness (outcome).
  • In what ways, was the outcome (for good, or not) a result of how the QM program was set up (organized) and/or the way it was implemented (delivered)?
community health center structure

Chicago Health Center

Board of Directors

QI Committee

of the Board

Executive Leadership


Staff QI Committee

Leadership Team

HIV Program Management Team

Consumer Advisory


HIV Program Staff

Community Health Center - Structure
waterbury hospital accountability structure diagram
Waterbury Hospital Accountability Structure - Diagram

Internal Communication

WHICH QM Committee

HIV Care Team

Consumer Advisory


Ryan White

Program Director

mdch ryan white part d quality management accountability chart structure
MDCH – Ryan White Part D Quality Management Accountability Chart - Structure

**All subcontracted agencies minimally participate in contractual Quality Improvement activities.

organizational quality assessment tool
Organizational Quality Assessment Tool



Creating Buy-in


A) Quality Structure

  • Organizational structure
  • Resources (staffing, program support staff)
  • Leadership
  • QM Plan, Annual QI Workplan (Action Plan)
structure contd
Structure contd

E) Staff Involvement

  • Engagement in staff in QI activities (process)
    • Staff trained (capacity, structure)
    • Attending training (process)

H) Clinical Information System

  • Information system in place
process and structure
Process and Structure

B) Quality Planning

  • Goals (process)
  • Roles and responsibilities (structure)
  • Annual QI Workplan (structure and process)
process contd
Process contd

D) Quality Improvement Activities

  • Conduct QI Projects to improve quality of care
  • Team approach (structure)
  • Use of QI methodology, reporting, etc

F) Consumer Involvement

  • Structure in place to gain input (structure)
  • Patient needs are assessed (process)
  • Results incorporated into goals (outcome)
  • Quality activity launched (process)
process contd1
Process contd

G) Evaluation of Quality Program

  • Review (process)
  • Results used to plan ahead (outcome)

C) Quality Performance Measurement

  • Selection of Quality Indicators (process)
  • Measurement of quality of care (process)
  • Results regularly reviewed and action taken (outcome)
gynecology exams
Gynecology Exams

Core Indicator


Grantee-wide Vision

Strategic QM Plan (3-5 yrs)

QM Plan

Annual Goals

***Annual QI Workplan

(Action Plan)


Annual Evaluation

action planning workplans
Action Planning (workplans)

Key components:

  • Goal
  • Activities
  • Who responsible
  • Timeline
Example: QM Program Workplan (Action Plan)Goal: Establish and implement an effective QM Program to improve patient care.
Example: QI Action PlanGoal: Improved quality of patient care as measured by specific performance indicators.
small group a exercise convert results of oa into an action plan for 2009
Small Group A Exercise: Convert results of OA into an Action Plan for 2009

Divide into groups of 5-6 members from a similar organization. You can have 2 members from the same program.

Task: Review results of your OA. Explain your program’s results to group members including, if applicable, what improvements in each domain you made in 2008 to achieve current score. Using the Annual QI Action Plan, state goal(s) and list activities your program could implement to achieve the goals by the end of 2009.

Supporting documents: 2008 QM Plan& Workplan….

small group b exercise completing an organization quality assessment
Small Group B Exercise: Completing an Organization Quality Assessment

Divide into groups of 3-4 members from a similar organization. You can have 2 members from the same program.

Task: Complete an Organization Quality Assessment for your program. Use the other members in your group as resources to better understand the descriptors for the scoring. Then, explain your assessment to another group member.

If time, complete Group A task.

Supporting documents: 2008 QM Plan& Workplan….

report out
Report Out

Group A recorders:

Write down the 3 common short term activities and 3 long term activities.

Select one of from each list that is the most important.

Share with large group.

wrap up summary q a evaluation
Wrap up: Summary, Q&A, Evaluation

Thank you for joining us today.

Have a wonderful HOLIDAY and Best Wishes for a Wonderful New Year ---- 2009!