Developing an Effective Quality Management Program in Accordance with the Ryan White CARE Act Frequently Asked Questions - PDF

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Developing an Effective Quality Management Program in Accordance with the Ryan White CARE Act Frequently Asked Questions This document is intended to explore some of the questions most frequently asked
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Developing an Effective Quality Management Program in Accordance with the Ryan White CARE Act Frequently Asked Questions This document is intended to explore some of the questions most frequently asked by programs that receive Ryan White CARE Act funds. It is our hope that it will assist organizations who are just starting to implement quality management activities, as well as those providers seeking to restructure or improve their quality management programs. While we are making every attempt to cover the broad topics brought to our attention by providers as well as HRSA Project Officers, this is not intended to be a replacement for the CARE Act Guidance Manuals applicable to each Title and Program. For further detailed information, please visit HRSA s HIV/AIDS Bureau website at hab.hrsa.gov. The following questions have been frequently asked and the corresponding answers are detailed in this document: Ryan White CARE Act and Legislative Quality Requirements What is the Ryan White CARE Act and what is its overall purpose?... 3 Is there an emphasis on quality management in the Ryan White Care Act?... 3 How is Quality defined in the context of the Ryan White CARE Act?... 3 What are the specific requirements regarding quality management and quality improvement in the Ryan White CARE Act?... 4 What is the overall purpose of a quality management program?... 4 What are the main characteristics of a sound quality management program?... 5 Quality Terminology What is the difference between quality improvement (QI) and quality assurance (QA)?... 6 What is the difference between quality improvement and evaluation?... 6 Is there a difference between a quality management program and a quality management (QM) plan or are those terms the same?... 6 Building an Effective Quality Management Program How do we put together a quality management program?... 8 Should we have a staff member designated just for quality management activities?... 9 We are a small agency funded to provide case management services only. Where do we get started?... 9 How do we incorporate quality improvement into the day-to-day activities of a Ryan White funded grantee? In an EMA, consortia or network model, who is responsible for ensuring the quality of services? How does HIPAA impact quality improvement activities? FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Quality Indicators and Data Collection What indicators should we be examining? Is there a minimum number of indicators that we should monitor? Is it enough to just focus on clinical care and not look at support services, such as case management? How do we avoid duplicate data collection for quality improvement activities for multiple funding sources and regulatory entities? Setting up Quality Improvement Teams Who should be part of the quality improvement teams? How do we keep busy physicians engaged in the process? How do we deal with difficult personality styles that are not always conducive to good teamwork? How can we ensure consumer input in our quality improvement activities? Overlap of External with Ryan White Quality Expectations I don t just provide HIV/AIDS services and I already have a quality management program, do I have to implement another one just for Ryan White services? Does the Ryan White quality management process supersede my current organizational standards and compliance measures? Ryan White Funding for Quality Management Do quality management activities count against the administrative cap? Is there Ryan White funding available to help programs establish quality management systems? Resources for Quality Improvement/Management Are experts available to assist us in establishing a quality management program? Where can I get more information about quality improvement? For further information, please contact the National Quality Center, a HRSA HIV/AIDS Bureau funded contractor to provide no-cost, state-of-the-art technical assistance to all Ryan White grantees to improve the quality of HIV care nationwide. Visit its website at NationalQualityCenter.org or call at 888-NQC-QI-TA. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Ryan White CARE Act and Legislative Quality Requirements What is the Ryan White CARE Act and what is its overall purpose? The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, enacted in 1990 and subsequently reauthorized and amended, provides funding to cities, States, and other public and private entities to address the unmet health needs of persons living with HIV disease by funding primary health care and support services that enhance access to and retention in care. The CARE Act reaches over 500,000 individuals each year, making it the Federal Government's largest program specifically for people living with HIV disease. Like many health problems, HIV disease disproportionately strikes people in poverty, racial/ethnic populations, and others who are underserved by healthcare and prevention systems. HIV often leads to poverty due to costly healthcare or an inability to work that is often accompanied by a loss of employer-related health insurance. CARE Act-funded programs are the payer of last resort by focusing on those persons living with HIV disease with low-incomes and who are uninsured or underinsured. Is there an emphasis on quality management in the Ryan White Care Act? Yes, in fact a major focus of the CARE Act is not only to eliminate barriers to accessing care, but also to improve the quality of care that its clients receive. New and significant legislative requirements found in the Ryan White Reauthorization of 2000 direct grantees to develop, implement, and monitor quality management programs to ensure that service providers adhere to established HIV clinical practices; quality improvement strategies include support services that help people receive appropriate HIV health care (e.g., transportation assistance, case management); and demographic, clinical, and health care utilization information is used to monitor trends in the spectrum of HIV-related illnesses and the local epidemic. How is Quality defined in the context of the Ryan White CARE Act? The HIV/AIDS Bureau (HAB) has defined quality as the degree to which a health or social service meets or exceeds established professional FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) standards and user expectations. Evaluation of the quality of care should consider a) the quality of the inputs, b) the quality of the service delivery process, and c) the quality of outcomes, in order to continuously improve systems of care for individuals and populations. This definition has been adopted from the Institute of Medicine s definition (Institute of Medicine Medicare: A Strategy for Quality Assurance, Vol. 2. ed. Kathleen Lohr. Washington, D.C.: National Academy Press) What are the specific requirements regarding quality management and quality improvement in the Ryan White CARE Act? The exact legislative quality management requirements vary slightly depending on the specific Ryan White funding. In general, the CARE Act legislation requires that a 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 (PHS) 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. Further details are available at the HRSA HIV/AIDS Bureau website [hab.hrsa.gov]. Title I: hab.hrsa.gov/tools/title1/t1secviichap5.htm Title II: hab.hrsa.gov/tools/title2/t2secviiichap5.htm Title III: hab.hrsa.gov/tools/title3 Title IV: hab.hrsa.gov/programs/factsheets/titleiv.htm What is the overall purpose of a quality management program? According to authorizing legislation, quality management (QM) programs should accomplish a three-fold purpose: 1. Assist direct service medical providers funded through the CARE Act in assuring that funded services adhere to established HIV clinical practice standards and Public Health Service Guidelines to the extent possible; 2. Ensure that strategies for improvements to quality medical care include vital health-related supportive services in achieving appropriate access and adherence with HIV medical care; and 3. Ensure that available demographic, clinical and health care utilization information is used to monitor the spectrum of HIV related illnesses and trends in the local epidemic. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) What are the main characteristics of a sound quality management program? In addition to being patient focused, HAB expects sound quality management (QM) programs should have the following key characteristics: 1. Be a systematic process with identified leadership, accountability, and dedicated resources available to the program; 2. Use data and measurable outcomes to determine progress toward relevant, evidenced-based benchmarks; 3. Focus on linkages, efficiencies and provider, and client expectation in addressing outcome improvement; 4. Be a continuous process that is adaptive to change and that fits within the framework of other programmatic quality assurance and quality improvement activities (i.e., Joint Commission on the Accreditation of Hospitals Organization (JCAHO), Medicaid, and other HRSA Programs); and 5. Ensure that data collected are fed back into the quality improvement process to assure that goals are accomplished and that they are concurrent with improved outcomes. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Quality Terminology What is the difference between quality improvement (QI) and quality assurance (QA)? Quality improvement (QI) refers to conducting proactive activities aimed at improving processes to enhance the quality of care and services. This approach to continuously study and improve care processes is used to meet the identified needs of service recipients. This term is also referred to concepts of continuous quality improvement and total quality management. Quality assurance (QA) refers to a broad spectrum of evaluation activities aimed solely at ensuring compliance with pre-established quality standards. Issues identified through quality assurance activities can be used to identify and prioritize areas for potential quality improvement projects thus building upon one another. What is the difference between quality improvement and evaluation? Quality improvement (QI) generally describes ongoing monitoring, evaluation and improvement processes aimed by improving prioritized service and care aspects. It is a patient/client-driven philosophy that focuses on preventing problems and maximizing quality of care outcomes. Evaluation is comprised of systemic studies conducted periodically or on an ad-hoc basis to assess how well a program or system of care is working. Types of evaluation include process or implementation evaluation, outcome evaluation, impact evaluation and cost-benefit and cost-effectiveness evaluation. For further information about evaluation, the HIV/AIDS Bureau has developed the Evaluation Monograph Series to assist CARE Act grantees in designing and implementing evaluation studies [available at hab.hrsa.gov]. Another resource is the following guide: Performance Measurement and Evaluation: Definition & Relationships, developed by the United States General Accounting Office [available at Is there a difference between a quality management program and a quality management (QM) plan or are those terms the same? FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Although those terms are very similar, they are used to describe different concepts. The term quality management program encompasses all granteespecific quality activities, including the formal organizational quality infrastructure (e.g., committee structures with stakeholders, providers and consumer) and quality improvement related activities (performance measurement, QI project and QI training activities). A quality management plan is a written document that outlines the grantee-wide quality management program, including a clear indication of responsibilities and accountability, performance measurement strategies and goals, and elaboration of processes for ongoing evaluation and assessment of the program. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Building an Effective Quality Management Program How do we put together a quality management program? It is important to have a quality management (QM) program in place with priorities supported by the leadership, by the providers in a service system, and by planning bodies. These priorities and the variety of quality activities should be routinely communicated to all program and provider staff. The quality management program development includes the 1. Formation of a sustainable quality infrastructure which includes the quality committee structures with stakeholders, providers and consumers; 2. Development of performance measurement systems to collect clinical and non-clinical data; 3. Initiation of quality improvement activities to improve key service areas as prioritized by internal and external stakeholders; and 4. Routine involvement of consumers and their families to ensure that the delivery of services is responsive to their changing needs, as defined by these communities. The Health Resources and Services Administration HIV/AIDS Bureau (HAB) Quality Management Technical Assistance Manual provides guidance outlining a nine-step approach for implementing an effective quality management program. This manual [available at hab.hrsa.gov] outlines the following steps: Step 1: Confirm Commitment of Leadership & Establish Supportive Organizational Structure Step 2: Establish Quality Management Plan Step 3: Determine Performance Measures & Collect Baseline Data Step 4: Analyze Data Step 5: Develop Project-Specific CQI Plan Step 6: Study and Understand the Process Step 7: Develop and Implement an Improvement Plan Step 8: Re-measurement Step 9: Celebrate Success Visit the NQC website at NationalQualityCenter.org for assessment tools to evaluate your quality management program. Other helpful models include the HIVQUAL Model, developed by New York State Department of Health AIDS Institute [www.hivqual.org] and the Logic Model, developed by United Way of America [national.unitedway.org]. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Should we have a staff member designated just for quality management activities? Many of the organizations have found it useful to allocate a position to focus on quality efforts. Whether a grantee decides to dedicate a full-time person or portion of a staff person s scope of work depends on active patient caseload, the HIV care delivery system, and available funds. Designating a job function to quality activities assures that those activities will become a priority and that QI will become part of the day-to-day operations of an organization or agency. We are a small agency funded to provide case management services only. Where do we get started? At first, a quality management (QM) program can seem overwhelming, especially for small agencies with limited staff and administrative personnel. Steps towards quality improvement are intended to be guiding principles that, if fully implemented, will lead to a strong sustainable quality management program. However, the most important step for you to take is to get started. Start with a self-assessment of your organization s approach to quality and efforts that are in place. For example: (a) you may already have data available to inform quality activities (such as number of missed appointments or acuity levels of clients in case management), but you ve never analyzed it in a formal manner; (b) you may have a team of case managers who are always finding ways to improve services (maybe this group can serve as your first QI project team); (c) you may be doing formal or informal client satisfaction assessment and have a history of responding to client suggestions for improvement; or (d) you do regular chart reviews to make sure program requirements such as Verification of HIV status are in place. It is critical to start with those activities, whether or not they are labeled quality improvement, that are already in place to assess and improve aspects of your service delivery. This will jump-start your efforts to build a sustainable quality program. Best practices from other grantees are available at NationalQualityCenter.org and at FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) How do we incorporate quality improvement into the day-to-day activities of a Ryan White funded grantee? A variety of approaches can be employed to integrate quality improvement activities into your day-to-day operations, whether you are an individual Ryan White funded provider, a Ryan White CARE Act grantee or administrative agency, or a Ryan White planning body. QI data collection, tracking systems and improvement strategies can be folded into daily workflow. At the individual agency, each staff member should be included on some level to promote shared accountability leading to buy-in on all levels. Job descriptions should include quality activities for every position. At the system level, all contracts should include specific language about expected QI activities, regular reporting and targeted outcome goals. Training of all stakeholders about quality improvement tools and techniques is very important. Understanding that the focus of quality improvement is improving systems of care, not evaluating individual agency or personnel performance, will help alleviate the most common resistance to undertaking QI initiatives. Encourage dialogue and suggestions about improving care delivery from every level of the system of care to further enhance stakeholder commitment to a quality management program. In an EMA, consortia or network model, who is responsible for ensuring the quality of services? The Ryan White grantee of record is ultimately responsible for assuring that quality services are being delivered in tandem with their network service providers. The individual administrative or lead agency, regardless of being a Title I, II, III or IV program, is responsible for ensuring the quality of services provided by each of the subcontractors. Although the methods vary by grantee, the most effective models have included quality activities as part of the RFP process and service contracting. This approach will ensure that each individual agency establishes its own quality management program. When data from multiple providers across the EMA, consortia or network are aggregated, a picture of the service-continuum can often be established, highlight grantee-wide patterns and offer concrete baselines for improvement activities. FAQ: Quality Management (03/2006) Developed by the National Quality Center (NQC) Administrative agencies should also use system-wide performance data results to ensure that subcontracted service providers with fewer resources receive adequate technical assistance and support. How does HIPAA impact quality improvement activities? HIPAA (Health Insurance Portability and Accountability Act) regulations are intended to standardize the way health care data are exchanged in order to streamline the processing of health care transactions, reduce the volume of paperwork and increase patient protection of confidential medical record and data. While safeguarding patient information, HIPAA states specific exemptions to allow for qualit
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