HRSA HIV/AIDS BUREAU

Transcription

1 HRSA HIV/AIDS BUREAU QUALITY MANAGEMENT & THE TITLE II PROGRAM: CRITICAL SUCCESS FACTORS, BARRIERS, CHALLENGES & OPPORTUNITIES FOR ENHANCING QUALITY MANAGEMENT IN TITLE II PROGRAMS

2 Quality Management & the Title II Program Table of Contents Overview and Background... 2 HAB Quality Management Priorities... 2 Institute of Medicine Reports... 3 HAB s Quality Management Activities... 4 Critical Success Factors and Challenges of Implementing Title II Quality Management Programs... 5 Critical Success Factors... 5 Barriers and Challenges... 8 Opportunities for Enhancing Quality Management Collaborative Learning Quality Management Recommendations Critical Building Blocks for Quality Management Programs Infrastructure Supports Effective Strategies Technical Assistance Recommendations Recommendations for HRSA/HAB Summary Attachments Attachment A: Title II Consultative Participant List ATTACHMENT D: HAB S QUALITY INITIATIVES Attachment F: Examples of Performance Measures and Quality Indicators Quality Management & the Title II Program Page 1

3 QUALITY MANAGEMENT & THE TITLE II PROGRAM: CRITICAL SUCCESS FACTORS, BARRIERS, CHALLENGES & OPPORTUNITIES FOR ENHANCING QUALITY MANAGEMENT IN TITLE II PROGRAMS Overview and Background The Health Resources and Services Administration s HIV/AIDS Bureau (HAB) convened a meeting of Title II representatives from low, medium and high incidence States to explore the range of quality initiatives that have been undertaken and identify the technical assistance needs of Title II grantees related to quality management. The meeting was held in Washington, DC on April 30, The goals of the consultative meeting were to: Clarify HRSA/HAB s expectations related to quality management; Explore various strategies being implemented by the States with regard to quality management; and Identify technical assistance needs to develop and support effective quality management efforts. The meeting design allowed participants to share best practices and strategies, and to highlight the technical assistance needs. The information gathered during the meeting has been used to develop a technical assistance strategy that will help the States best address and implement quality improvement and quality management initiatives. Appendices A and B outline the list of participants and session agenda, respectively. HAB Quality Management Priorities HAB defines quality as the degree to which a health or social service meets or exceeds established professional standards and user expectations. Evaluations of the quality of care should consider the quality of: the personnel and resources available to them (structure), the service delivery process, and outcomes. Quality improvement (QI) is an ongoing process that involves organizational members in monitoring and evaluating inputs, processes, outputs and outcomes in order to continuously improve service delivery. In contrast to quality assurance, which focuses on identifying and solving problems, CQI seeks to prevent problems and to maximize quality of care. (Source: HIV/AIDS Evaluation Monograph Report #4.) The quality management legislative requirements are the same for Titles I and II. The requirement is The chief elected official/ grantee shall provide for the establishment of a quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV health services. Quality Management & the Title II Program Page 2

4 The purpose of a QM program is to ensure that: Services adhere to PHS guidelines and established clinical practice; Program improvements include supportive services linked to access and adherence to medical care; and Demographic, clinical, and utilization data are used to evaluate and address characteristics of the local epidemic. Any effective QM program will be able to document five key characteristics: Use a systematic process. The process should include clearly identified leadership and accountability, and allocate sufficient dedicated resources to support the activities. Establish benchmarks. Data and measurable outcomes should be used to determine progress toward relevant, evidence-based benchmarks. Be focused. Linkages, efficiencies, and provider and client expectations should be a primary focus for addressing outcome improvement. Be adaptable. The process should be continuous, adaptive to change and able to fit within the framework of other programmatic quality assurance and quality improvement activities, (i.e. JCAHO, Medicaid and other HRSA programs). Result in improved outcomes. Data collected should be fed back into the quality management process to assure that goals are accomplished and improved outcomes are realized. Institute of Medicine Reports Two reports published by the Institute of Medicine (IOM) reinforce the need for health care organizations to focus on quality efforts. The first report, Crossing the Quality Chasm 1, highlights how the healthcare system falls short in translating scientific knowledge into practice and effectively using available evidence. The system often has a poor use of resources and results in a high percentage of medical errors. The report points out that The current care system cannot do the job; trying harder will not work; changing care systems will. The second report, Measuring What Matters 2, focuses on allocation, planning and quality assessment for the Ryan White CARE Act. In examining the assessment of quality in CARE Act programs, the study found that the use of existing outcome measures is appropriate but not sufficient. There are many factors beyond the grantees control and structure and process measures can help identify areas of improvement. The quality measures that are in use are clinically appropriate but are not standardized and are limited to patient-level clinical data. Measures of access to needed medical and non-medical services are lacking and the current efforts to assess overall quality of care are rudimentary. Though essential in HIV care, population-based measures are not generally in use. 1 Institute of Medicine (2001). Crossing the Quality Chasm. National Academy Press: Washington, DC. 2 Institute of Medicine (2004). Measuring What Matters: Allocation, Planning and Quality Assessment for the Ryan White CARE Act. National Academy Press: Washington, DC. Quality Management & the Title II Program Page 3

5 Within the second IOM report, a conceptual framework to assess quality and access to CARE Act-funded services is proposed and includes four areas of focus: Population of Interest (undiagnosed & not in care, diagnosed & not in care, diagnosed & in care); Level of Assessment (individual, provider/clinic, population/area); Type of Measure (structure, process, outcome); and Spectrum of Services (prevention to counseling/testing and referral to care to service integration & coordination). The IOM reports raise issues that are important for consideration as the HIV/AIDS Bureau (HAB) and CARE Act grantees implement quality programs. HAB s Quality Management Activities HAB is committed to high quality healthcare and support services for people living with HIV/AIDS. Helping Ryan White CARE Act grantees develop quality programs and the capacity to measure the performance of these programs over time is one of the four Bureau priorities. Several quality initiatives are supported by HAB which aim at addressing quality improvement in the areas of care, services, financing, and outcomes. These technical assistance initiatives include provision of on-site/off-site consultation, material development, resources allocation, and delivery of training. A summary of HAB s quality initiatives are included in Appendix C. As there are many models of quality improvement to select from, grantees are encouraged to use the best framework or model that fits and resonates with their organization, clinic or program. Specific examples include the HIVQUAL model, the Institute for Healthcare Improvement s Chronic Care Model and the Model for Improvement and the United Way s Logic Model. Outlined in the Bureau s Quality Management TA Manual 3, a 9-step model, which is outlined below, is another framework that can be employed. Step 1: Confirm commitment of leadership and establish supportive organizational structure Step 2: Establish quality management plan Step 3: Determine performance measures and collect baseline data Step 4: Analyze data Step 5: Develop project-specific QI plan Step 6: Study and understand the process Step 7: Develop and implement an improvement plan Step 8: Re-measurement Step 9: Celebrate success 3 HIV/AIDS Bureau/HRSA (2003). Quality Management Technical Assistance Manual Available online at Quality Management & the Title II Program Page 4

6 Critical Success Factors and Challenges of Implementing Title II Quality Management Programs Common themes related to critical success factors, barriers and challenges were identified during the TII consultative meeting. The common themes are summarized below and are presented along with examples from the participating States. Critical Success Factors The factors that were most frequently associated with successful quality management programs may be grouped into the following six categories: 1) involvement of stakeholders; 2) focus on processes & systems; 3) development of standards of care; 4) methods and approaches; 5) infrastructure support; and 6) using performance data for quality improvement. Involvement of Stakeholders: Quality improvement initiatives tend to have better success when the system is created with the involvement of stakeholders, such as providers and consumers. By closely integrating the quality efforts with the community, the QM program becomes acceptable to the ultimate users and the incentive for focusing on quality activities is enhanced. Participation and buy-in is also enhanced when conscious efforts are made to collaborate across programs and organizations. Soliciting input from high-volume sites or leaders in the community can also serve to heighten the focus on quality initiatives. As quality management programs are developed and refined, key points to consider in respect to representation and participation include the following: Ensure close integration of quality efforts with the community; Create a system through the input of key stakeholders, e.g. providers and consumers; Solicit input from high-volume sites or providers; Make conscious efforts to collaborate across the programs and organizations; and Utilize leaders in the region or community to heighten awareness of quality initiatives. Through the Missouri AIDS Case Management Improvement Project (MACMIP), the Missouri Title II Program has utilized representation from the provider and consumer community to improve the Statewide case management system. MACMIP has resulted in new standards of care for case management services and created a new case management process. Performance measures have been integrated into the standards of care thereby enabling the State to trend data over time. Quarterly meetings are held with MACMIP and the CARE Act grantees to review data and discuss the process for ongoing measurement. In Utah, the HIV Treatment & Care Planning Committee of the Statewide HIV Advisory Council serves as the oversight body for quality improvement activities. This committee consists of up to 35 members with membership from consumers (35%), service providers (35%), advocates or other interested parties (18%) and government agencies (12%). Of Quality Management & the Title II Program Page 5

7 these members, 10-15% must represent rural areas. This is another example of involving the key stakeholders in quality improvement efforts. Beginning in 2002, North Carolina established a goal to initiate a collaborative, cross-title quality improvement program for the State. They felt that a QI program adopted by all CARE Act providers in the State best served the interest of individuals with HIV/AIDS. A QI workgroup was convened and represented consumers, case managers, primary care providers, consortia administrators, data management and quality assurance personnel across the State. Through the larger advisory group and a smaller QI workgroup, quality indicators were identified and refined, a draft QI plan was developed and a plan for providing training and technical assistance was created. Focus on Processes & Systems: A clear process and system for quality improvement is needed for a successful program. By focusing on a systems assessment and threading quality management through all activities, quality can become part of the organizational culture. And by involving the key stakeholders in its creation, support and buy-in of the processes is reinforced. Specific ways in which systems and processes have been used within Title II Programs include redesigning patient progress notes, revising ADAP application forms and streamlining site visit forms. Select Title II Programs have also used formal improvement or learning collaborative models to provide the framework for building capacity for quality improvement. Other examples include: North Carolina has adopted the glossary of terms outlined in HAB s Quality Management TA Manual 4 and Florida utilizes concepts from the Baldrige Criteria 5, AmbuQual s Parameters of Quality 6 and the Care Model 7. Development of Standards of Care: Standards of care can be extremely helpful in setting and defining the expectations of care for the provider agencies and drive the scope of work. Among the 12 States that were represented at the meeting, all had established standards of care for at least one service category. As standards are developed, a glossary of terms that is comprehensive in scope may be helpful to establish a common language. Several of the States have incorporated performance measures into the standards of care. Examples of specific performance measures are included in Appendix D. In revising the standards in Missouri, four process principles were utilized to guide the revision: 1) the standards must be client-driven; 2) acuity-based; 3) place an importance on cultural awareness; and 4) focus on outcomes. In an attempt to coordinate quality improvement activities related to standards of care, outcomes and trainings, Connecticut is working across the Titles I, II, III and IV programs. Methods and Approaches: To carefully plan for quality activities, several of the States suggested using an incremental approach, such as establishing a quality management plan 4 HIV/AIDS Bureau/HRSA (2003). Quality Management Technical Assistance Manual Available online at 5 The Baldrige National Quality Program (2005). Education Criteria for Performance Excellence. 6 Benson, D. & Miller, J. (2003). AmbuQual II - The Book. 7 Institute for Health Care Improvement (2002). HIV/AIDS Disease Training Manual. Quality Management & the Title II Program Page 6

8 and defining quality indicators for a single service category rather than defining the indicators for all categories at once. Several Title II Programs selected indicators based on defined standards of care and data that are accessible through CAREWare. As standards are defined, it is also important to pilot test the standards prior to rolling them out as a final product. The Title II Programs in California and Connecticut stress the importance of working closely with surveillance and epidemiology programs. Several of the States have also benefited from Statewide advisory bodies which provide oversight for quality management. For instance, Connecticut utilizes the Statewide HIV/AIDS Consortia to address quality management activities and North Carolina is in the process of setting up an advisory committee to work with the Title II Administrator. Other States, such as Virginia and Florida, have implemented comprehensive site visits that identify strengths and weaknesses of the programs, highlight areas for improvement, offer specific recommendations and provide on-site education and technical assistance. California is implementing a Site Visit Tool Review Project which will review the various site visit tools used by programs to determine if commonalities can be collapsed into a single document. The goal is to reduce the number of duplicate questions and explore the potential for monitoring multiple programs in one site visit. A statewide assessment of quality management systems was conducted in Florida. The assessment began at the administrative level with the Title II grantee of record and was then deployed statewide. The assessment has been used to build upon their quality efforts and initiate training for the subcontractors. Some States have implemented formal methods or models of improvement, such as a Learning Collaborative model. Others have used aim worksheets or PDSA (plan-dostudy-act) cycles to focus on a process 8. Infrastructure Support: Without the proper infrastructure, quality management efforts will not be effective or sustained over time. Critical infrastructure supports include allocation of resources for quality activities, formal oversight of the quality management program and provision of training and technical assistance. Clearly identifying funds to support quality efforts emphasizes the role quality plays in the Title II program. Financial support for quality efforts varies across the programs. Among the 12 States represented, funds allocated for quality management ranged from $12K to over $513K. In some States, quality management experts were retained for completion of defined tasks while in other States, all of the quality efforts were completed by the Title II staff. In those States that used Title II staff to complete the quality efforts, some of the States had staff dedicated to the quality program while others included quality as a portion of their job. The delineation of formal oversight of the quality management program has also been proven to be effective. In some of the lower incidence States, a single Quality Management 8 Institute for Health Care Improvement (2002). HIV/AIDS Disease Training Manual. Quality Management & the Title II Program Page 7

9 Administrator or QI Coordinator spearheads the quality efforts. In the higher incidence States, such as Florida and California, entire divisions or programs have been established. Building quality management expectations into the contract of subcontractors is also helpful. By incorporating clear and concise terms in the contract, the subcontractors understand the requirements they are agreeing to when they accept the Title II funds. Ongoing training and technical assistance is also seen as a critical success factor. As part of their quality improvement program, the majority of States offer training programs and/or technical assistance to their subcontractors. In Washington, new case managers are required to participate in a mandatory training program related to the system acuity measurement process that has been implemented. Florida is implementing problem solving training for its contractors. Using Performance Data for Quality Improvement: Without data and performance measurement, a program can not determine if a change is truly an improvement. Massachusetts has found that multiple sources of data are critical for better understanding the service needs of PLWH/A. These data can be used to inform quality improvement activities, program development, innovations in service delivery and provide direction for new initiatives. CAREWare is a management information system that helps grantees and service providers collect, manage and report client-level data and has been used by some Title II Programs for quality efforts. Oregon uses CAREWare to monitor disease progression through trending of CD4 and viral load counts over time. Other States have coordinated their quality programs with the Uniform Data Set while others review data from the Universal Reporting System (URS). Data are available in many different formats and have been used effectively by the different programs to impact patient care. For instance, Washington s ADAP monitors the use of Gancyclovir rather than focusing on eligibility criteria. If patients are on Gancyclovir and full price is being paid, it serves as a red flag to see if the clients are eligible for Medicaid. By moving the clients over to Medicaid, CARE Act resources can be maximized. Site visits and annual audits are two common approaches that Title II programs use to assess and measure performance. By reporting low performing indicators back to the providers, an opportunity to improve performance is provided. As data are trended over time, the top performing indicators can serve as benchmarks for the subcontractors. Addressing data needs, both automating and streamlining data and information systems, is an important element to consider. Data can only be useful to the extent it is available. If information is not readily shared with the subcontractors, the opportunities to positively impact care and services are lost. Barriers and Challenges A variety of barriers and challenges have been identified by the Title II programs and focus on six (6) main areas: 1) eligibility and access; 2) time and resources; 3) participation and Quality Management & the Title II Program Page 8

10 representation; 4) education and training; 5) measurement and data management; and 6) systems/infrastructure. Eligibility and Access: Documenting eligibility and tracking Medicaid applications and denials are examples of two challenges that are faced. The issue of State of residence versus State of diagnosis also comes into play as allocation of resources is made at the Federal level. Increased morbidity is another challenge the Title II programs are facing. As the number of clients enrolled in programs steadily increase, a decrease in access to care or limited services may result. Time and Resources: Allocating the time and resources for quality efforts is yet another challenge that is faced. Establishing solid quality management systems takes both time and money, and in the face of level or decreased funding, it becomes even more challenging to maintain the quality efforts. Charts reviews are often labor intensive and with many States dependent on State funding or other funding streams, the ability to measure performance becomes a difficult task to undertake and maintain over time. And as staff change, at both the grantee and subcontractor level, so does the institutional knowledge which can adversely impact performance. Participation and Representation: In order to maintain quality efforts, continued focus on garnering leadership and buy-in is essential, but not always readily apparent. With competing priorities, establishing and maintaining quality committees can become a challenge in and of themselves, especially when involvement of providers and consumers is sought. At times, quality committees can become isolated or disengaged from the community they are striving to serve if engagement does not occur on an ongoing basis. Education and Training: As new systems, processes or expectations are put into place, subcontractors must be informed of the changes. Ongoing education or training is often needed in order for the service providers to become familiar with the processes and at times may seem a luxury. Performance Measurement and Data Management: In respect to performance measurement and data management, timely reporting of data is a significant challenge. This is an issue that is present at the subcontractor, State and Federal level. There is a need to identify additional benchmarks and standards across disciplines and service categories and place a greater emphasis on outcome measurement. Performance measures or indicators have not been defined by HRSA and many grantees struggle with identifying appropriate measures. Understanding of measurement and data management continues to be a challenge and the need for IT support is considerable. The implementation of new data systems is resourceintensive and the maintenance of the systems requires significant support. The capacity to review encounter data is also a challenge that is faced. Systems & Infrastructure: Changes within the field of HIV require frequent process changes and reflection and it is not uncommon for extensive changes to occur in State funding in regards to other services, such as mental health. While change can lead to opportunities for improvement, living in an environment of constant change becomes a challenge in itself. Quality Management & the Title II Program Page 9

11 In respect to infrastructure, the lack of an organizational structure or support from leadership significantly impacts the ability to implement quality activities. If infrastructure is not in place to collect or manage the data, another layer of complexity is added. As the expectations related to quality management and performance measurement continue to increase, the added responsibility can lead to resistance by staff and subcontractors. Opportunities for Enhancing Quality Management Programs Potential opportunities for enhancing quality management at the national, state and programmatic levels include the following: Sharing data across the Titles and closer integration of the types of data collected; Developing standards by service category; Setting benchmarks as improvements in the gaps (how to analyze data and focus on opportunities for improvement); Establishing uniform client data systems, coordination, and resources to support all aspects of data management, including reporting and useful feedback to providers; Encouraging alignment and integration of QM activities across programs; and Standardizing indicators, performance measures, assessments, surveys, etc. Collaborative Learning In 1999, the HIV/AIDS Bureau partnered with the Institute for Healthcare Improvement (IHI) to explore ways to implement programs based on HAB s quality management goals. Three models, the Learning Model, the Improvement Model and the Chronic Care Model, were successfully piloted in projects with Title III & IV grantees, to enhance health care services for those with HIV/AIDS. A second pilot Demonstration Project for Title I grantees was implemented from August 2002 through May 2004 to test the Collaborative approach in the Title I environment. Five Eligible Metropolitan Areas (EMAs) were recruited to participate in the Title I Collaborative Demonstration Project: Atlanta, Baltimore, Denver, Kansas City, and Oakland. Each participating EMA established a working group for the project called an EMA Response Team, which included a representative from the following groups: Title I Administrative Agent, Title II, Planning Council, and the AIDS Education and Training Center (AETC). The role of the EMA Response Team was to focus on improving quality of care delivery across the EMA and facilitate the work of five provider teams who were also involved in the Collaborative. The Collaborative faculty worked with the teams to guide and mentor them and facilitate co-mentoring. The long-range goals of the Demonstration Project were to maximize the length and quality of life for patients with HIV/AIDS and satisfy patient and caregiver needs and expectations. These goals were achieved by implementing a system-wide model of care, using the Chronic Care Model and the Model for Improvement to focus on assuring the delivery of evidencebased clinical care within a context of culturally and linguistically competent and appropriate services, with strong support for self-management. Quality Management & the Title II Program Page 10

12 The Title I Demonstration Project built upon the experiences of a Title III and IV Collaborative. The Title III/IV Collaborative focused on individual clinics or programs and was a natural fit for the Chronic Care Model as these programs are based on the medical model. The Title III/IV Collaborative focused on medical outcomes and measures and individual client data were readily obtained. In contrast, the Title I Demonstration Project focused on a local care network and incorporated medical, case management and process measures. Because the focus was on a local care network instead of an individual agency, the Care Model did not fit as naturally. Individual client data was not readily available, multiple populations of focus were defined rather than a single population and community planning was needed for communities to buy into quality improvement. By focusing on case management and medical teams, the groups began to look at the system differently with clinical and social service as a whole, rather than separate parts. Relationships outside of individual agencies were enhanced and several teams participating in the Title I Demonstration Project felt that it facilitated their work and improved care. Based on the Title I Demonstration Project, learning took place in regards to the: Power of the Plan-Do-Study-Act (PDSA) cycle as a tool for change; Complexity and dynamic state of the HIV care system; Critical importance of leadership to the success of quality improvement; and The challenge of data collection and analysis and the need for timely data and results. The lessons learned from the Title III/IV Collaborative and the Title I Demonstration Project were useful in considering the application of the Collaborative model to Title II. Unique challenges and opportunities such as the following were identified: The Title II program includes both ADAP and the Title II base and both had to be considered. Title II grantees are responsible for the system of care throughout the State. Traditional top-down quality assurance programs may not lead to system-wide quality improvement. A thorough understanding of the HIV care system throughout the State is fundamental--you need to know how the networks work. Integrated data systems are not the norm; data analysis is often not available to front line staff in real time. Measures for quality and improvement are less likely to be biomedical and more related to process and infrastructure. Biomedical measures do not serve as good measures for systems functioning. Programs need to be nimble. Rigid QM programs are jeopardized by changes in other programs that have a significant impact on Title II. There is a need for buy-in and active engagement by the leadership. There is an authority-accountability mismatch: if you are held accountable for things you have no authority to change, you can at least measure and try to identify who has the authority to change it. Quality Management & the Title II Program Page 11

13 These challenges and opportunities were used to help shape and define the Title II Demonstration Collaborative, which began in June 2005 and involves eight States and jurisdictions. Quality Management Recommendations I. Recommendations to Develop and Maintain Effective Quality Management Programs a) Critical Building Blocks to establish Quality Management Programs Critical building blocks identified for establishing a quality management program centered on six main areas: 1) involving stakeholders; 2) building performance measurement & data systems; 3) methods & approaches; 4) identifying time & resources; 5) setting clear standards & guidance; and 6) training & education. Involving Stakeholders: As the quality program is conceptualized, all CARE Act grantees should be involved and other potential key stakeholders identified. It s important for the providers and leaders to commit to quality management in order for the program to be successful. To the extent possible, other health and human service agencies and networks should also be engaged, e.g. Medicaid. Building Performance Measurement & Data Systems: As performance measurement is defined, the process should begin with simple steps; start with one measure and build upon it. Consensus across the State should be gained regarding the measures. As the management of data is explored, consistent data systems that support integrated and shared data are critical. The data systems must be able to show trending over multiple years. People start to best understand after two years of data collection. Data that are currently collected should also be reviewed and its use maximized. Performance measurement, while important, is only one piece of the puzzle. As data are gathered, the information should be reviewed to identify areas for improvement and specific improvement projects implemented. As quality improvement projects are undertaken, the quality of care will be enhanced. Methods & Approaches: As previously mentioned, it is important to start simple and implement steps that can be measured so that the stakeholders can see the results. And once results are available, they should be shared in a timely fashion. Delineating and formalizing the vision, mission and plan for the quality management program will help clarify the priority of tasks and communicate what needs to be accomplished. An effective feedback loop needs to be established to connect all aspects of the quality program and sharing of resources should be encouraged. Marketing the QM program to the stakeholders can also help garner support and buy-in. A consistent methodology for implementing quality improvement should be established and standardization of forms and processes should be undertaken. Quality management should Quality Management & the Title II Program Page 12

14 be tied to unmet need. Reporting and quality management requirements of HRSA and other funding sources should also be taken into consideration. Identifying Time & Resources: Resources dedicated to build, support and maintain a quality program are essential. Resources include financial support through the CARE Act and other sources of funding, as well as resources such as personnel, supplies, equipment, etc. Designated staff for quality-related functions allows the QI program to be operational. Allocating the time to participate in quality activities is another necessary commodity, at both the grantee and subcontractor level. The quality improvement and performance measurement methodology selected each have cost implications and should be considered as the program is established. As with many of the other issues, the cost issue applies at both the grantee and subcontractor level. Setting Clear Standards & Guidance: Standards of care should serve as the cornerstone for performance measurement and quality improvement activities. To the extent possible, consistency in definitions should be the goal for HRSA, CDC and between the Titles. Clear guidance from HRSA is needed related to the quality management expectations and performance measures that should be tracked. Training & Education: As quality management expectations are established, it is important to assess and understand the capabilities of the subcontractors. The use of a common language is essential and it maybe helpful to define the terms that are being used, such as in a glossary of terms. Getting people to buy-in to a process begins with them understanding the process, so training, education and technical assistance is critical. To the extent possible, practical applications should be used. b) Infrastructure Support for Quality Management Programs Once quality management and improvement programs are established, infrastructure supports are required to sustain the program. A list of the infrastructure supports identified by the meeting participants is listed below: Consistent guidance, expectations, standards as they relate to quality; Financial support for quality activities; Allocation of resources for staff, education, quality management experts, and IT support; Regional or statewide training on quality-related issues; Buy-in and support from leadership at all levels with continued recognition that quality management is more of a priority; Involvement of all stakeholders in the quality process on an ongoing basis; Buy-in from planning bodies; Keeping other Titles informed of quality activities being undertaken; Philosophical shift of viewing and integrating quality management into the culture rather than being seen or presented as a separate task or chore to complete; Development of a quality management program that is nimble and responsive to the needs of the organization or system; Formalized policies and procedures to make it clear what is going to happen; Quality Management & the Title II Program Page 13

15 Establish corrective action plans for sites with low compliance through use of a technical assistance, non-punitive approach; Useful data systems that are flexible, expandable, reliable and accurate; Ability to report data to the community on an ongoing basis; Routine dissemination of information and facilitation of information sharing; Build a calendar of activities around the time when quality management reports are due; Set new targets, standards, and processes (e.g., annually) over time; and Establish a listserv specifically for QM issues and discussion. c) Effective Approaches to Strengthen a Quality Management Programs The most effective strategies identified range from the simple to the complex. Most of the discussion focused on three core areas: 1) utilizing an incremental approach; 2) leveraging resources and expertise; and 3) communicating effectively. Incremental Approach: The most important message is to begin. It doesn t matter what you start with or how much you understand or know. The work should begin incrementally rather than trying to do everything at once. Patience is needed as the vision unfolds and maintaining flexibility, in the plan, ideas and goals should be sought. Timeframes should be established with a focus on short-term goals to celebrate successes as well as longer-term goals to strive for. A mechanism for feedback should be incorporated into the process along with timely decision-making. Instead of re-creating the wheel, use quality management tools that have already been created and develop new tools as needed. Training should be practical and workable for all stakeholders and adequate preparation and timeframes should be established. As quality projects are undertaken, set them up as pilot projects rather than statewide. Think in terms of increments or stepping stones and allocate the needed staff time to the projects. Leveraging Resources & Expertise: Within the Title II program, it is essential to have inhouse expertise and leadership. Advice should be sought from others to utilize best practices. Adequate preparation needs to take place and a reasonable time line for the process should be clearly articulated. Timely decision-making is critical and as standards are developed, key stakeholders should be involved in the process. Communication: One of the most important activities that can be undertaken is to engender buy-in from all of the partners and key stakeholders. Communication and training is a critical component and can lead to the development of trust between partners and learning the art of compromise. Feedback should be provided on a constant basis and clarification should be provided regarding policies and expectations. The establishment of clear and concise standards can help clarify points of ambiguity and peer pressure can become a powerful motivator to jumpstart non-responsive partners. Quality Management & the Title II Program Page 14

16 II. Recommendations to Provide Technical Assistance to Title II Programs on Quality Management A full range of potential technical assistance strategies were identified by the meeting participants as a way to support Title II programs as they develop and implement quality management programs. These strategies focused on three main areas: 1) models of training and technical assistance; 2) sharing resources within and across grantees and Titles; 3) and standardizing processes. Training & TA Models: Listed below are a variety of training and technical assistance models that were brainstormed: Establish a Listserv specifically related to quality management and quality improvement; Create a QM technical assistance bank account for each grantee and allow each grantee to decide how they will use the allotted TA hours; Develop training curricula for Title II programs to use with their sub-grantees and post on a website for expanded access; Offer training, technical assistance, and an array of QI tools; Provide individualized on-site QM TA for the purposes of assessment and help the program shape and develop a QM plan; Convene meetings for like-sized States (low incidence, medium, high) to discuss QM-related issues specific to their States; Provide technical assistance around data management issues to focus the data that should or could be collected, advise on existing or available software, etc.; Spotlight manuals that are available to grantees and highlight ways in which it can be used, e.g. QM TA manual; Establish a roving QM HAB staff member/project officer to visit programs and provide TA across the country; Development a format for programs to conduct a self-assessment of their QM TA needs; Implement a Title II Collaborative Demonstration Project similar to the Title I Demonstration Project; Offer train-the-trainer workshops; Conduct on-site visits from the Project Officer to help with issues related to leadership and management buy-in; and Show how QM fits together, rather than a piecemeal approach. Sharing Resources: The following points focus on sharing resources and information: Establish a repository or clearinghouse for all QM-related forms and projects; Enhance HAB s website on QM; Post sample policies and procedures on the website; Encourage Titles to collaborate on quality activities in a similar manner as the Statewide Coordinated Statement of Need is used; Quality Management & the Title II Program Page 15

17 Offer a quality management meeting that was similar in format to a meeting presented on unmet needs; Provide States with a model that has been piloted or offer a couple to choose from, e.g. Collaborative Learning; Utilize site visits for sharing information and providing guidance on quality activities. Standardization: The following points focus on standardizing processes: Establish a glossary of terms to reinforce consistent language; Outline the minimum QM components and standards from HRSA; Clarify support service definitions the medical model is clear, but not for other service categories, such as transportation or emergency assistance; Provide examples on performance measures and indicators; Develop a model where everyone can follow the same basic steps; Develop a system-level assessment or model that will work at multiple agency levels (hospital, State, etc.); and Develop free data system for needs that go beyond CAREWare. III. Recommendations for HRSA/HAB After considering the full range of strategies that could potentially be explored, the meeting participants prioritized the strategies into four primary areas: 1) legislative and regulatory changes; 2) opportunities for integration; 3) training and education; and 4) methods of communication. Legislative & Regulatory Changes: Listed below are the recommendations specifically related to legislative and regulatory changes. Clarify the quality management expectations in the legislation or the program guidances, e.g. required performance measures, expectation of a dedicated staff member focused on quality efforts, etc.; Streamline the grantee reporting guidelines; Work with CMS and the Veterans Administration for access to and sharing of Medicaid data; Promote universal health insurance; and Work with CMS to provide coverage for all PLWH/A. Opportunities for Integration: Listed below are the recommendations related to integration. Implement an IHI Collaborative for Title II and utilize graduates from the Title I and III Collaborative as faculty; Develop a matrix of different States QM initiatives; Work with physician structures to increase QM activities; Contract with successful Title II QM representatives to provide TA for other Title II programs; Utilize the AIDS Education and Training Centers to reinforce the quality management messages and provide training; Quality Management & the Title II Program Page 16

18 Mandate collaboration across Titles in respect to quality management and give Title II the authority since they are responsible for SCSN; Change QM allocation from up to 5 percent to a minimum of 5 percent ; Coordinate with CDC on data and data elements, e.g., race and ethnicity categories are not consistent; Consolidate the requirements outlined by HAB, e.g. unmet need, SCSN, needs assessment, etc. Education: Listed below are recommendations related to education and training. Offer CATIE library updates; Develop train-the-trainer and self-learning modules; Implement a roving QM project officer with experience at the State level to provide TA; Pilot QM processes before requiring them in all the States; Provide process and tools for self-assessment; Develop quick, concise expectations, standards and core measures; Implement a longer QM consultative meeting than the April 2004 consultative meeting and use it as a tool for educating grantees. Communication: Recommendations regarding communication are provided below. Establish a listserv for quality-related issues; Formalize a HRSA statement of expectations in regards to collaborating on quality management efforts across Titles; Have like-sized meetings with similar-incidence States as a forum for sharing information; Establish Communities in Practice conference calls once a month; Develop communication technologies (conference calls, website, meeting networking) for purposes of sharing information in regards to quality efforts; Identify clear types of activities for like States, e.g. peer-to-peer activities; Put all recommendations into a work plan and disseminate; Involve NASTAD in QM initiatives; Mandate attendance at meetings such as the April 2004 Title II quality management consultative meeting to make it easier for Title II to get approval from their States; and Provide advanced notification of application and form changes. Summary A significant number of recommendations and considerations were identified through the Title II Consultative Meeting. This information, along with other, has been used to formulate a strategy to assist Title II programs as they continue to implement and improve their own quality management programs. Since the consultative meeting took place in April Quality Management & the Title II Program Page 17

19 2004, a wide variety of activities have been put into place and resources have been established. Listed below is a sampling of these activities. Title II Collaborative Demonstration Project: HAB launched the Title II Collaborative Demonstration Project Improving Care for People Living with HIV Disease in June A total of eight States elected to participate in the Collaborative: Alabama, the District of Columbia, Florida, Georgia, Michigan, Missouri, Ohio and Oregon. The overarching purpose of the Collaborative is to improve the quality of care for people living with HIV in the defined state or jurisdiction. Through creating an effective and actionable quality management plan, and assuming a direct role in support of quality improvement activities in the state or jurisdiction, Collaborative participants are conceptualizing and implementing quality management programs, and developing supporting infrastructures across the defined service areas that are consistent with legislative requirements and guidance expectations for Title II. The scope of the Collaborative includes opportunities to explore and test strategies that focus improvements on four main areas: 1. Alignment Across Jurisdictions and Services, including ADAP, to support a common vision of service delivery and quality of services; 2. Integration of Data and Information Systems to facilitate information sharing and performance measurement to support delivery of quality health services; 3. Improving Access to Care and Retention of HIV/AIDS Clients; and 4. Optimization and Management of Resources within the currently constrained environment including recruitment and retention of personnel. By the end of the Collaborative, Title II Grantees will have: Developed or refined an effective quality management plan and program for the state or jurisdiction in accordance with the Ryan White CARE Act legislation, and initiated implementation of processes to ensure and demonstrate quality of care and services; Tested and implemented changes in at least two of the bulleted areas above; and Developed plans to support ongoing and collaborative quality improvement efforts, through integrating and using the tools made available during the Collaborative to administer their own statewide Collaborative. The Collaborative is designed to run for 18 months and utilizes a variety of TA strategies, such as face-to-face meetings, conference calls, virtual meetings, intranet and listserv. Low Incidence Initiative: Low incidence States face different challenges when implementing quality management programs. A formal TA strategy to address the issues is being planned to target low incidence States. An initial face-to-face meeting will be held with 18 low incidence/low resourced States in June The initiative will utilize a combination of TA strategies, such as face-to-face meetings, workshops offered at the 2006 All Titles meeting, conference calls and virtual meetings. The overall goals of the initiative are to: 1. Assist LI states in complying with QM mandates; 2. Identify a pool of consultants that can provide TA to the low incidence States; 3. Provide technical assistance to low incidence States; 4. Organize a body of information to help HAB develop future policy guidelines; Quality Management & the Title II Program Page 18

20 5. Identify strategies for on-going dialogue on low incidence QM issues, e.g. Extranet, peer learning, etc..); 6. Develop a publication to share successful strategies with other HAB and HRSA grantees from low incidence States. Technical Assistance: In 2004 the National Quality Improvement/Quality Management TA Center was funded by HAB to provide a range of quality-related consultative services for CARE Act grantees to include: 1) information dissemination; 2) training and educational forums; and 3) intensive on- and off-site consultation. As part of the trainings and workshops, two Quality Institutes will be offered at the 2006 All Titles meeting and will offer a novice and advanced track to address the range of expertise. TA calls have focused on the development of quality management plans. Resources and Documents: Various documents and resource materials have been created. Recent documents have included the following: Title I Quality Management TA Manual Quality Management Frequently Asked Questions Quality Management Program Assessment Tools As evidenced by the work undertaken before and after the April 2004 consultative meeting, HAB continues to focus on quality initiatives and actively seeks ways to support grantees in their quality endeavors. Quality Management & the Title II Program Page 19