Implementing Agency-wide Quality Improvement Plans, Los Angeles County Experience

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.