BVCOG Quality Management Plan / 2017-2021

THEBVCOG HIVQUALITYMANAGEMENTPLAN

I.QualityStatement

The overall goal of the Brazos Valley Council of Governments (BVCOG) HIV Program is to provide optimal healthcare to People Living with HIV/AIDS (PLWHA) in the Central Texas HIV Administrative Service Area.

TheultimategoaloftheprogramistobuildaQuality Management (QM)structurethatis sustainableandusedinadynamicwaytoimprovecareandservicesto ensure optimal wellbeing in support of the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009).

II. Quality Management Program Infrastructure

Leadership.

The QM Program is guided by the QM committee.

QM Committee

The Quality Management Committee is made up of the following members with the following roles and responsibilities:

  • BVCOG HIV Program Manager: QM Committee Chair. Responsible for overseeing the QM process and ensuring compliance with DSHS and HRSA guidelines. Reports on client grievances.
  • BVCOG HIV Program Data Manager: runs reports for the committee.
  • BVCOG HIV Program Planner: reports on community input.
  • BVCOG HIV Program Compliance Monitor: reports on issues with subcontractor monitoring.
  • BVCOG Contract and Quality Management Coordinator: reports on expenditures and changes to contracts. Schedules meetings and types Quality Management Committee meeting minutes.
  • Medical Staff with HIV Experience: Provides guidance on medically – related quality issues, provides guidance on the development and evaluation of outcome measures. Provides feedback on the Standards of care.
  • Community Members with HIV experience: provides input on QM Processes and quality of services. Adds perspective to community collaboration.
  • Service Providers:Adds service provider perspective.
  • Consumers: Adds consumer perspective to activities.

The Quality Management Committee will meet quarterly.

Resources

BVCOG will utilize the Plan-Do-Study-Act (PDSA) model for testing changes to determine their effectiveness to improving outcomes. Using the model will allow BVCOG to test the change on a small scale, see how it works, and refine the change if necessary before implementing it on a broader scale.

  • PDSA Cycles

During the planning state, the QM Committee members will develop a plan outlining the steps to be taken during throughout the PDSA cycle. The plan will identify the quality issue being addressed, the change to be implemented, the actions steps that will be taken and the individuals responsible for implementation of each step, the timeline for the PDSA cycle, and the intended or anticipated outcomes. The plan will also identify any test groups to be used, as well as a plan for collecting baseline data if necessary.

Once the change is implemented on a small scale, the QM Committee will reconvene to study the results of the change. During the review, committee members will ask the following questions:

What did we expect to happen?

What did happen?

Did we meet our objectives?

Were there unintended consequences?

What was the best thing about this change?

The worst?

What might we do next?

The QM Committee will then determine whether the change should be implemented on a broader scale and whether the change or implementation process should be adjusted. If the plan is going to be implemented on a broader scale, the committee will develop a plan for implementation, addressing the same areas as the previous plan. If the committee determines that the plan should not be implemented on a broader scale, the committee will discuss other strategies for addressing the quality issue.

Other resources include datafromproviders,on-sitereviews,teleconferences,reports,studies,andassessments todocumentthestatusandimprovementsintheHIVcontinuumofcareandcustomerservice. QIconsultationis available toorganizationsinvolvedincontractingforandprovidingHIVservices. QMfacilitatessystem-widecontinual improvementwhileassistingstakeholders/contractors withtheirownqualityprogramdevelopmentintheirserviceareas.

StandardsofOperationandService

BVCOGusesstandardsrequiredforfederalgranteessuchastheU.S. Public Health Standards (USPHS)and GuidelinesfortheTreatmentofHIVDisease. ClinicalandadministrativestandardsareavailabletothepublicviatheDSHS HIV/STD Program web site. State-level Standards of Care(located at for each core and supportive service categories were developed, finalized, and implemented beginning in January 2015. To accompany these SOC, uniform monitoring tools were also written.

BVCOG also uses DSHS Program Operating Procedures and Standards (POPS)includingtheclinical,administrativeandotherrequirementsfortheservicedeliverysystem. Confidentialityprotections,documented intheregulations,along with standardsandpoliciesareacriticalpartofthequality assessments.

DataManagementandMeasurements

A key resource for theBVCOG QM program is the AIDS Regional Information and Evaluation System (ARIES), a custom, web-based, centralized HIV/AIDS client management system that provides a single point of entry for client-related data, allows for coordination of client services among providers and provides comprehensive data for program monitoring and evaluation. ARIES enhances services for clients with HIV by helping providers automate, plan, manage, and report on client data.

Technical Assistance

Technical Assistance (TA) is available through HRSA/HAB, the National Quality Center (NCQ), and other local or national organizations.

III. Performance Measurement

Data Collection: BVCOG is responsible for the collection of data and provides the Quality Management Committee information from the following data sources: the client data system (ARIES), client records, provider semiannual reports, provider surveys, site visit reports, and other data as necessary.

Client Satisfaction: Service providers are contractually required to measure client satisfaction annually. They report their results to BVCOG in their semiannual reports and BVCOG also reviews the results of those satisfaction surveys during the review of quality management activities during annual site visits.

Annual Chart Reviews: Chart reviews are performed annually at each service provider for each core medical and support service funded by BVCOG. HOPWA files are also reviewed. Each agency receives a report based on the result of their chart review and must address the areas that have been identified as needing improvement. Each agency must develop a Plan of Correction to address deficiencies.

Performance Indicators: BVCOG’s Quality Management program uses the strategies outlined in the HIV/AIDS Bureau (HAB) HIV/AIDS Core Clinical Performance Measures for Adults and Adolescents to evaluate performance across the Central Texas planning area. By examining and tracking these measures, BVCOG can assist service providers in improving the health outcomes for their clients. BVCOG is working with service providers to assist them in improving both their data entry to improve the HAB measure numbers as well as improving their processes to improve the HAB measure numbers. These numbers will be reviewed quarterly again, once the reports are up and running again in ARIES. The Performance Measures that BVCOG includes in service provider contracts are located in Appendix A.

IV. Quality Performance Objectives

The measures that BVCOG will be focusing on for this period are below:

Program / Goal
HIV Care Services / 85% of all diagnosed persons living with HIV will be retained in care (baseline 70%)
For all priority groups* 86% of newly diagnosed persons will be linked to HIV medical care within one month of their diagnosis and retained in care within six months of linkage (baseline ranges from 72%-86%)
For all priority groups* 88% ofpersons who are retained in HIV medical care will be virally suppressed (baseline ranges from 64%-88%)

*Priority groups include the following: Black women, men who have sex with men (MSM), White MSM, Black MSM, and Hispanic MSM.

We will be working with service providers to improve their HAB measures overall, which will, in turn, increase the number of individual who are retained in care.

V. Participation of Stakeholders

Stakeholder Participation / Involvement in Program / Program Communication Method
Providers /
  • Assist the AA in meeting the medical and supportive services needs of PLWHA.
  • Adhere to standards of care specific to their program service area(s)
  • Develop a quality management plan for their agency.
  • Ensure that quality management components of their contract are met.
  • Provide AA with requested data in respective service category
  • Participates in continuous quality improvement.
  • Provides information via annual satisfaction survey of the AA.
/
  • Quarterly QM Meetings.
  • Technical assistance and education via NQC tutorials and quality improvement workshops.
  • Quarterly QM performance reports
  • Detailed annual QM performance reports

Quality Management Committee /
  • Determines quality goals and improvement priorities.
  • Participate in discussions about performance results
  • Participate in quality improvement projects as needed.
  • Review needs assessment and epidemiological data to identify quality improvement needs at a systems level.
  • Identifies core measures and outcomes.
  • Makes suggestions/recommendations to providers on quality improvement needs.
/
  • Quarterly meetings.
  • Written and verbal reports.

AA /
  • Provides technical support and data on services utilization.
  • Ensure that quality management components of their contract are met.
  • Makes suggestions/recommendations to providers on quality improvement needs.
  • Provides input on QM activities.
  • Support quality development with training programs.
  • Initiates Quality Committees.
/
  • Email
  • Written and verbal reports
  • Written data requests.

Clients /
  • Provide feedback via annual community input meetings.
  • Provide feedback via annual client satisfaction surveys at their service provider.
/
  • Annual Community Input meetings

VI. Evaluation

BVCOG has assisted service providers in setting baseline numbers for their service objectives and will continue to help them improve these scores. This information will be used to guide program improvement efforts and determine where changes are needed. In the long term, evaluation results may also serve to guide service planning, priority setting and funding allocations.

Evaluation of the current plan cannot take place until February2018 since the following was established in 2017:

  • Five-year plan,
  • First year implementation plan, and
  • Expanded QM committee.

The BVCOG Program Manager will create an evaluation document in the form of a summary of the QM plan for the year. Will be completed in February of each year.

  1. The evaluation will include the following elements, at a minimum:
  2. A review of the goals of the QM Program and QM Committee
  3. A summary documenting results of the QM Plan
  4. A review of complaints received and other quality-related concerns identified throughout the year
  5. A review of corrective actions taken to address concerns/issues identified
  6. A review and analysis of QM objectives and program outcomes, including the relationship between Standards of Care and QM Outcomes, including comparing annual QU goals with year-end results.
  7. Recommendations for improvement of the QM Plan, the QM Committee, and quality improvement activities
  8. The evaluation will assist BVCOG in the development of new goals and objectives for the upcoming contract year and revisions of the QM Plan.
  9. The completed QM evaluation will be shared with departmental staff and BVCOG management. QM activities and evaluation information will be reported to DSHS in semiannual reports and otherwise as required.

The Evaluation Summary will be emailed to the QM committee prior to the second meeting of the year to review and edit. The Evaluation summary will be presented and approved at the Second Quarter meeting.

VII. Capacity Building

BVCOG will continue to build capacity by providing relevant training and technical assistance. The technical assistance related to QI/QM for staff and providers will be determined by through semiannual reports, surveys, and quality compliance reviews. BVCOG staff participates in the National Quality Center (NQC) and other Ryan White QM trainings as needed. BVCOG staff hold trainings and offer TA on QM in addition to ad hoc TA that may be requested by individual agencies. Each year, BVCOG staff will have at least one meeting with providers to review processes and issues identified from chart reviews and offer recommendations and provide technical assistance for performance improvement initiatives. This is usually completed as a part of an annual site review.

The Texas HIV Cascades will be disseminated and discussed with stakeholders to increase knowledge and understanding of regional continuum of care outcomes. Further capacity building will occur regarding parity amongst priority populations.

VIII. Process to Update QM Plan

On an annual basis, in August, the Quality Management Committee will review and update the QM Plan. The update will include performance measures, goals and performance data. The BVCOG Program Manager will draft edits to the plan and present to the committee for approval at the last meeting of the year.

IX Communication

Communication will be necessary with the following groups:

  • Contracted Service Providers
  • DSHS Staff and their contractors
  • City of Austin
  • Quality Management Committee

Communication methods will depend on the needs and requirements of the individuals and may include:

  • Email
  • Phone calls
  • Face to face meetings
  • Webinars

The frequency of communication will vary depending on the needs and requirements of the individuals or groups and will occur as necessary. BVCOG communicates with service providers regarding quality issues during annual site visits and when providers submit their semiannual reports. The BVCOG QM Committee meets quarterly, so there is communication with that committee on at least a quarterly basis.

X QM Plan Implementation

See Appendix B for the Implementation plan

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