Clemens Steinbock, MBA Director, National Quality Center

1. Lessons Learned for Part B Quality Programs: Experiences from HAB/NQC Part B CollaborativesAug 25, 2008 Clemens Steinbock, MBA Director, National Quality Center Panel:Rosemary Donnelly, MSN, APRN-BC, ACRN; Jay Adams, MA; Jamie Cotnoir, MPH; Susan DiCocco, RN

2. Today’s Agenda • Role of the State (Part B Programs) • Overview of HAB/NQC Part B Collaboratives: Part B Collaborative and Part B Low Incidence Initiative • Lessons Learned and Tips for Part B Programs • Words of Wisdom from Collaborative Participants • Q&A • Workshop Evaluation

3. Role of the State • As State Health Departments, Part B programs play the dual role of sponsoring their own quality management programs and of championing quality improvement for subgrantees and other providers in the state. • Its dominant role provides an impetus to lead across the entire Ryan White HIV/AIDS Program-funded continuum and to build bridges between Ryan White HIV/AIDS Program-funded grantees within their constituency.

4. HAB/NQC Part B Collaborative • Managed by the National Quality Center (NQC) • Initiated in November 2004, and ended in November 2006 • 3 Face-to-face Learning Sessions • 8 Ryan White Part B grantees: Alabama, District of Columbia, Florida, Georgia, Michigan, Missouri, Ohio, Oregon • Potential impact: 129,000 people living with HIV/AIDS

5. Part B Collaborative: Aim Improve the quality of care for people living with HIV in the state or jurisdiction through creating an effective quality management programs in the following four domains: • Alignment across jurisdictions and resources • Optimization and management of resources • Integration of data and information systems • Improving access to care and retention of HIV/AIDS clients

6. Part B Collaborative: Timeline • Vanguard Meeting - November 2004 • Expert Meeting - January 2005 • Planning Group Meeting - May 2005 • Learning Session 1 - June 2005 • Learning Session 2 - November 2005 • Virtual Meeting - May 2006 • Learning Session 3 - November 2006 • Synthesis Meeting - March 2007

7. Part B Collaborative: Measures • Percent of ADAP applicants approved/denied for ADAP enrollment within two weeks of receiving a complete application • Percent of ADAP enrollees recertified for ADAP eligibility criteria annually • Percent of individuals newly reported with HIV infection who also have AIDS diagnosis • Percent of individuals newly reported with HIV infection who progress to AIDS diagnosis within 12 months of HIV diagnosis

8. Part B Collaborative: Measures (con’t) • Ratio of individuals who die within 12 months of HIV diagnosis to the number of individuals newly reported with HIV infection • Percent of individuals with at least two general HIV medical care visits in the last 12 months • Percent of individuals with either a CD4 or viral load in the last 6 months

9. Collaborative Goal Part B Collaborative: QM Program Assessments A.1quality management plan A.2performance measures A.3 work plan B.1organizational structure B.2QM committee B.3involvement of stakeholders B.4evaluation processes C.1performance data collection C.2QI projects C.3QI training and TA

10. Part B Collaborative Percentage of newly applying state ADAP clients approved or denied for ADAP services within 2 weeks of ADAP receiving a complete application

11. Part B Collaborative Percent of clients with an AIDS diagnosis at first HIV disease report

12. Part B Collaborative Percent of clients who progress to AIDS diagnosis within 12 months of HIV diagnosis

13. Part B Collaborative Percent of clients who die within 12 months of HIV diagnosis

14. Part B Collaborative Change in definition Percent of clients with two (2) primary care visits in the last 12 months

15. Part B Collaborative Percentage of newly applying state ADAP clients approved or denied for ADAP services within 2 weeks of ADAP receiving a complete application.

16. HAB/NQC Part B Low Incidence Initiative • Managed by the National Quality Center (NQC) • Jun 2006 - May 2008 • 2 face-to-face and 1 virtual Learning Session • 17 states: Alaska, Hawaii, Idaho, Iowa, Kansas, Maine, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Utah, Vermont, West Virginia, and Wyoming • Potential impact: over 20,000 people living with HIV/AIDS

17. Part B Low Incidence Initiative Aim Development or refinement an effective quality management plan and program for the state or territory in accordance with the Ryan White Program legislation, and implementation of processes to ensure and demonstrate quality of care and services.

18. Part B Low Incidence Initiative: Timeline • Major Milestones: • Jun 06 - Consultative Meeting, Washington, DC • Dec 06 - Draft of needs assessment report • Apr 07 - Kick-off Meeting in Washington, DC • Aug 07 - Face-to-face QI training in Chicago, IL • Aug 07 - First performance data report (17 out of 17 submitted) • Feb 08 - Virtual Meeting • May 08 - Final face-to-face meeting-

19. Low Incidence Initiative: Goals • Completion of a comprehensive Quality Management Plan. • Development and/or strengthening of a Quality Management Committee within their State/Jurisdiction. • Ability to regularly collect, trend and report quality data. • Initiation of at least one improvement project within the 12-month period. • Improvement in the Quality Management Program core criteria self-assessment.

20. Low Incidence Initiative: Key Measures • Percent of Ryan White funded clients who have a CD4+ test done at least every six months • Percent of applying state ADAP clients approved/denied for ADAP services within two weeks of ADAP receiving a complete application • Percent of clients with at least two general HIV medical care visits in the last 12 months who are enrolled in case management

21. Low Incidence Initiative: Results • States have developed/improved performance measurement systems to collect data for quality management and report on Initiative measures bi-monthly • 13 states submitted written QM Plans for review • All states formed QM Committees and 9 have met • States are beginning to initiate quality improvement projects to react to data • Several developing relationships with Part C • Several sharing data with stakeholders

22. Low Incidence Initiative: % CD 4 Tests at least every six months

23. Low Incidence Initiative: % of ADAP clients approved/denied within 2 weeks of application

24. Low Incidence Initiative: % of clients with at least 2 HIV medical care visits in last 12 mths, enrolled in CM

25. Map of all Part B Programs Engaged (2007)* NQC has recently also received TA requests from Michigan, Pennsylvania, Texas and Nevada Part B Programs = Part B Collaborative = Low Incidence Initiative = On-site TA Request = Regional Trainings

26. What We’ve Learned and Gathered… Real-World Tips on: • Focusing on Key Activities • Staffing for Quality • Engaging Key Leaders • Integrating Quality Management Across Departments • Involving Senior Clinicians • Involving Consumers • Keeping Performance Measurement Simple • Planning Your Cross-Part Quality Meeting • Celebrating Success

27. Real-World Tips: Focusing on Key Activities • Develop a Part B QM Plan and QM Committee • Identify measures, data sources, and indicators • Collect and analyze data • Interpret results • Identify and implement programmatic changes • Communicate outcomes of QM activities to leaders, subgrantees and others

28. Real-World Tips: Staffing for Quality • Designate a single person to be responsible for QM activities • Determine how much time is necessary to fulfill the requirements of the position (i.e., full-time, part-time) • Develop a job description • If unable to hire staff, explore use of a consultant with expertise in QM

29. Real-World Tips: How to Engage Key Leaders • Emphasize that QM is a requirement for funding and use HAB’s quality language. • Share key performance data in clear and simple formats (e.g., graphs, charts, storyboards, etc.) as well as QI projects and outcomes. • Provide training on quality improvement; make it a required activity if possible or provide it at regular meetings of senior management. • Share success stories from other states; invite out-of-state speakers. • Ask senior leadership to officially sign off on the QM plan; if they sign off on it, they are more interested in its success.

30. Real-World Tips: How to Engage Key Leaders (con’t) • Turnover in senior management can make it difficult to sustain interest in QM; cultivate mid-level staff, these members are less prone to political turnover. • Routinely bring up quality issues in meetings with senior leadership. • Show cost benefit and resource savings (taking money away from direct services can SAVE money and make more money available for direct services); consider focusing initially on high-cost areas where QM may result in larger savings. • Invite key leaders to give a presentation or participate on a panel at a QM-related meeting. • Work with others in your jurisdiction (e.g., Part A or Part C grantees, local health departments, other service providers) that may have more influence with senior leadership.

31. Real-World Tips: Integrating Quality Management Across Departments • Link QM activities the Statewide Coordinated Statement of Need (SCSN) process. • Link QM to other health department priorities, such as reducing health disparities. • Attend other quality-related meetings within the health department. • Link Part B QM to other QM efforts in the state (e.g., Healthy People 2010, public health accreditation). • Use QM as an opportunity to increase alignment across Ryan White HIV/AIDS Program grantees in the jurisdiction. • Integrate QM across diseases (e.g., STD, TB, chronic disease) and bureaus/departments. • Communicate your successes to other departments, especially those related to saving money or improving client outcomes.

32. Real-World Tips: Involving Senior Clinicians • Convene a medical advisory panel that meet via email; ask for volunteers as they are the most motivated to participate. • Start a dialogue with providers to engage them in the process; with a communication process in place, providers will be more likely to provide advice on how to facilitate their involvement. • Include a clinician as a consultant to your program to provide advice and serve as a model for other providers. • Network with medical schools to reach future providers.

33. Real-World Tips: Involving Consumers • Include consumers on your QM committee; ask subgrantees and providers to recommend consumers for this purpose as a starting point; consider developing an orientation package for this purpose. • Establish a state-wide consumer advisory committee for consumers to communicate concerns and ideas for improving quality of care; be sure to follow-up on recommendations, where appropriate, and develop a communication link to your statewide QM committee. • Involve consumers in the process of developing quality performance indicators, often consumers and clinicians prioritize needs differently.

34. Real-World Tips: Involving Consumers (con’t) • Use patient satisfaction surveys, focus groups, and/or key informant interviews to obtain feedback on quality of care issues. • Include consumers on specific quality improvement projects and teams to improve specific HIV care issues. • Include consumers as staff for regular consumer feedback to your program and to facilitate/moderate other forms of consumer feedback in your state. • Build the capacity of consumers for quality improvement by provide learning opportunities and opportunities to meet key stakeholders.

35. Real-World Tips: Keeping Performance Measurement Simple • Realize that there is no ‘perfect indicator.’ • Beg, borrow, and steal indicators (HAB, HIVQUAL, NQC, NY State, National Quality Measures Clearinghouse, etc.) • Use only as much data as necessary. • Train staff in data collection processes and address data interpretation issues. • Limit data analysis to the achievement of identified indicators. • Communicate project data early on; don’t wait to get perfect results. • Performance measurement is only the first step—use your data for quality improvement.

36. Real World Tips: Data Collection Techniques • Data collection should be coordinated for multiple projects, with different projects using the same data—collect mutually beneficial data. • Create a part-time data position to collect data from various efforts such as performance management, subgrantees, and client satisfaction surveys. • Make the data gathering process formal, either through letters of agreement with agencies or through a contract that provides access to data. • Engage clinicians and frontline staff through regular feedback on QM efforts. • Demonstrate how poor data reporting from staff and subgranteess can misinform decisions; for example, show how incomplete forms submitted by clinicians can misrepresent who is being served and the services provided. • Provide consistent training on data collection.

37. Real World Tips:Planning Your Cross-Part Quality Meeting • Use existing cross-Part meetings to initiate discussion around QM (i.e. statewide HIV/AIDS conferences, etc). • Consider the use of an external facilitator with expertise in QM for your first meeting. • Form a planning group with representatives from each Part to develop the goals of meeting and to set the agenda and continue momentum after the meeting. • Develop common QM goals and priorities and measures. • Develop a cross-Part written QM plan and implementation plan with assigned roles and a timeline to ensure momentum is implemented.

38. Real World Tips:Planning Your Cross-Part Quality Meeting (con’t) • Develop a final product/outcome from your initial meeting (i.e., an action plan) and use workgroups/breakout groups during meeting to get work done. • Have all Parts sign-off on shared documents created. • Include senior leaders from each Part to make the decision-making process easier. • Engage providers of HIV care who are not funded by the Ryan White HIV/AIDS Program in the QM effort in order to make it a truly state-wide improvement effort. • Include consumer input in the state-wide QM effort to strengthen efforts.

39. Real World Tip: Celebrate Success! • Build excitement for quality by publicizing success stories in newsletters and journals. • Mount success storyboards openly so that providers and patients can see them. • Establish an annual awards program for quality improvement. • Report successes to funders and in reports to internal and external councils and stakeholders.

40. Stay Tuned for… ‘NQC Guide for Statewide Quality Management Programs: Practical Approaches to Build the Capacity of Ryan White HIV/AIDS Program Part B Grantees’ …to be published September 2008

41. Words of Wisdom from Collaborative Participants Rosemary Donnelly, MSN, APRN-BC, ACRN PHSO Nurse Consultant HIV Division, Georgia Division of Public Health rdonnelly@dhr.state.ga.us (404) 463-0415 Jay Adams, MA HIV Care Coordinator West Virginia Ryan White Part B Programs jayadams3@sbcglobal.net (304) 232-6822 Jamie Cotnoir, MPH Maine Center for Disease Control jamie.cotnoir@maine.gov (207)287-5539 Susan DiCocco, RN Quality Management Administrator Ohio Part B Program Susan.DiCocco@odh.ohio.gov (614)644-5686

42. National Quality Center (NQC) • NYSDOH AIDS Institute • 90 Church Street—13th Floor • New York, NY 10007-2919 • 888-NQC-QI-TA • Info@NationalQualityCenter.org • www.NationalQualityCenter.org