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Engaging StakeholdersThrough Quality Management

National Latino HIV and HCV Conference – San Antonio, TX

May 19, 2018

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Disclosures

The presenter has no financial relationships to disclose.

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Learning Objectives

Describe the framework for clinical quality management in HIV programs

Use available performance measurement data to identify disparities in HIV care using an evidence-informed tool

Identify evidence-informed improvement interventions appropriate to improve health equity leveraging stakeholder input

Use available performance measurement data for public relations and marketing purposes

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Clinical Quality Management FrameworkPolicy Clarification Notice 15-02

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HRSA-HAB Policy Clarification Notice 15-02

The HIV/AIDS Bureau’s requirements regarding clinical quality management based on the Ryan White HIV/AIDS Program legislation

Applies to recipients of all Parts funding and their subrecipients

The focus is on improving HIV health outcomes

Available at: https://hab.hrsa.gov/sites/default/files/hab/clinical-quality-management/clinicalqualitymanagementpcn.pdf

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Components of a CQM Program

CQM programs coordinate activities aimed at improving patient care and patient satisfaction to drive health outcomes improvement

CQM activities should be continuous and fit within and support the framework of grant administrative functions

Components of a CQM program

1. Infrastructure

2. Performance measurement

3. Quality improvement

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Grant Administration

Grant administration refers to the activities associated with administering a RWHAP grant or cooperative agreement

The intent of grant administration is not to improve health outcomes. Therefore, they are not CQM activities

Grant Administration ≠ Clinical Quality Management

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Examples – Grant Admin vs. CQM

Grant Administration Creating a performance

measurement system to collect minimum data required by the RWHAP legislation and HAB

Creating care systems and service standards

Management of mandated reporting

Provider training geared toward compliance

Clinical Quality Management Creating a sophisticated

performance measurement system to collect service data tied to HIV health outcomes

Tests of change to improve care, systems, or standards

Management of peer learning and collaboration programs

Provider training geared toward improving HIV health outcomes (evidence-based/evidence-informed)

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Quality Assurance vs Quality Improvement

Quality assurance:

Refers to a broad spectrum of activities aimed at ensuring compliance with minimum quality standards

Include the retrospective process of measuring compliance with standards

Part of the larger administrative function of a recipient’s program or organization and informs the CQM program

Quality Assurance ≠ Quality Improvement

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Examples – QA vs. QI

Quality Assurance Measuring compliance with

standards / Contract monitoring / Chart reviews

Focused on individual “bad apples”

Responsibility of a few to carryout

Quality Improvement Continuously improving

performance beyond minimum service standards

Focuses on health systems and processes

Responsibility of all

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Performance Measurement DataThe things you are already required to collect

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Traditional Performance Measurement

HAB Performance Measures

Identifying core performance measures that are most critical to the care and treatment of people living with HIV

Combining performance measures to address people of all ages living with HIV

Promoting relevant performance measures used in other federal programs

Archiving performance measures that are no longer consistent with U.S. Department of Health and Human Services guidelines or applicable to the general population

https://hab.hrsa.gov/clinical-quality-management/performance-measure-portfolio

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RWHAP Reporting Requirements

Ryan White Services Report

Network primary recipient requirements

ADAP Services Report

Dental Services Report

https://hab.hrsa.gov/program-grants-management/data-reporting-requirements-and-technical-assistance

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Strategies for Enhanced Data Management

Data element and measures inventories

Use this to manage waste through duplicated reporting requirements (or slight differences)

Test for completeness and performance Identify priorities for data cleaning and data collection process improvement

Drill down clinical measures included in required reporting using demographic and clinical data

Identify priorities for “story-telling” and QI

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Data Element and Measures Inventories

Simple lists of all data elements and performance measures you need to collect

Include level of detail (e.g., is transgender T or is it MTF and FTM? What is the cut off for VS?)

Put it in excel so you can sort and filter

Double check for duplicates and NEGOTIATE!

Update data collection to include the MOST granular level wherever you land

This is a Data Dictionary!

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Data Element Completeness

Garbage in, Garbage out…

Where are there holes in the data? Use excel to identify cross-sectional holes

What holes can be “padded”?

What holes can you live with and what ones do you need to fill to tell your story?

Work with patient and staff groups to identify ways to increase data completeness from both sides of the desk

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Testing Performance Measures

Run all required performance measures and populate the results in a table like for the data element inventory

Ideally, populate a calculator or other tool that can be modified to answer questions you have about your data

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Experience Data

Don’t forget our Quadruple Aim!

Improving patient outcomes

Improving patient experience

Decreasing costs

Joy in work (improving staff experience)

Experience data complements outcome and cost data and is important to the community you serve

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Patient Experience

A measure of your patients’ morale

Red flags and important areas of investigation

Trends over time

Influences retention in care, health seeking behavior, patient attitudes toward staff

Can be responsible for poor retention in addition to patient population expansion (word of mouth travels fast)

Identifies areas of potential concern to community

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Staff Experience

A measure of staff morale

Red flags and important areas of investigation

Trends over time

Influences the care provided and the environment where patients are treated

Can be responsible for downward spirals in addition to forward motion

Identifies areas of patient care, care environment and staff supports that require improvement

TRAUMA can affect your staff, too

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Leveraging Data for Health EquityUsing the data you already collect for noble purposes

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Step 1: Performance Measurement

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You’re Already Doing It!

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Health Disparity Calculator – Data Entry

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Health Disparity Calculator - Analysis

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Step 2: Root Cause Analysis

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5 Whys Analysis

The root cause is “the evil at the bottom” that sets in motion the entire cause-and-effect chain causing the problem(s)

Some root cause analysis approaches are geared more toward identifying true root causes than others; some are more general problem-solving techniques, while others simply offer support for the core activity of root cause analysis

By becoming acquainted with the root cause analysis toolbox, you’ll be able to apply the appropriate technique or tool to address a specific problem

http://asq.org/learn-about-quality/root-cause-analysis/overview/overview.html

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Cause and Effect Diagrams

http://www.ihi.org/resources/Pages/Tools/CauseandEffectDiagram.aspx

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Root Cause Analysis is Important!

Organizes and displays all causes and sub-causes that may influence a problem, outcome, or effect

Helps push people to think beyond the obvious causes, (money, time) to find some causes thatthey can fix/improve

Helps organize potential solutions and make clear who should be involved in solutions

Encourages a balanced view

Demonstrates complexity of the problem

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Step 3: Prioritize

Random House Webster’s College Dictionary

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Potential Projects

What is the

potential

impact?

How many

patients will it

affect?

Do you have

the data?

Do you have the

support and

resources?

Is it reasonable

achievable &

feasible?

Total Score

VLS

Retention

Perinatal trans.

Dental

Pap

Simple Priority Matrix

These can be scored via scale

“10” is the most positive response

“1” is the least positive response

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Benefit/Effort Matrix –CompletedTable

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A

B

C

D

E

FG

H

I

J

K L

M

N

O

P

QR

S

T

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10

Ben

efi

t

Effort

Pursue

Consider

Avoid, if Possible

Benefit/Effort Matrix –Plotted Matrix

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Step 4: PDSA Cycles

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Model for Improvement

https://careacttarget.org/cqii

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ActAdapt?

Adopt ? Abandon?

Next cycle?

PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle(who, what, where, when)

StudyComplete the

analysis of the dataCompare data to

predictionsSummarize what

was learned

DoCarry out the plan(on a small scale) Document problemsand unexpectedobservationsBegin analysis

https://careacttarget.org/cqii

The PDSA Cycle

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Why Test?

Increase your confidence that the change will result in improvement in your organization

Learn to adapt the change to conditions in the local environment

Minimize resistance when you move to implementation

https://careacttarget.org/cqii

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CHANGE: New Follow-up Protocol for No-Shows

AIM: Reduce Gaps in Care Over 3 Months

A P

S D

A P

S D

Cycle 1A: Revise evidence-informed template form and test with one of Jo’s clients on Tuesday

Cycle 1B: Revise form based on learning and test again with Karl’s clients next Monday

Cycle 1C: Present refined form to all case managers and document feedback

Cycle 1D: Revise and test form with all clients for one week

Cycle 1: Implement form throughout program

https://careacttarget.org/cqii

PDSA Cycle Example

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Tips for PDSA Cycles

“What change could you test by next Tuesday?”

Learn from others (‘Steal shamelessly, Share senselessly’)

“Rule of 1”: 1 facility, 1 office, 1 provider, 1 patient

Volunteers at first

Useful, not perfect, data

Customized measures for tests of change are recommended

https://careacttarget.org/cqii

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Step 5: Training/Spreading Change

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Newsletters and Social Media

Goals include letting the communities you serve know all you are doing for them Use your data and the results of your QI activities

Be action-oriented in requests

Utilize a “campaign” mentality

Go-in with community partnerswho serve your clients in different settings

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Presentations

Town hall meetings

Create a local conference Invite other agencies

Invite consumers

Invite non-traditional partners

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Bring in New Team Members

Think about the communities you serve

Consumers, obviously

Minority communities (i.e., LGBT)

Other vulnerable populations

Is your staff reflective of the communities you serve?

Are there liaisons that can help you fosterrelationships with segments of your servicepopulation who are hard to engage?

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end+disparities ECHO Collaborative

The 18-month collaborative aims to increase local quality improvement capacity and to increase viral suppression rates in four pre-selected populations based on CDC data. Participants help create a national community of learners from diverse program types, settings, and geographic locations. The initiative is managed by the Center for Quality Improvement & Innovation(CQII), funded by the HRSA Ryan White HIV/AIDS Program (RWHAP) and developed using the Project Extension for Community Health Outcomes (ECHO) model.

https://careacttarget.org/cqii/end-disparities-echo-collaborative

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Leveraging Data Beyond Quality ManagementThe magic of data can help you in innumerable ways

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Public Relations

Leverage the information you have to tell compelling stories

Cater information to specific audiences and their preferences

Demographic information

Longitudinal performance by group What are you doing to help these folks?

How can the community get involved in your work?

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Marketing and Advertising

What makes your organization stand out?

Against others in your area?

In comparison with the whole country?

Do you serve special populations well?

How do you add value to individual lives or to communities of people? Why come to your

organization vs another organization nearby?

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Grant Writing

Goes well beyond research!

Use your data to RESPOND to RFA/FOA

Use your data to APPROACH a funder Not unlike an informational interview

PITCH PITCH PITCH!!

Use your data to identify new community partners to go in on a grant together Draw in collaborators!

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Know Your Purpose, Know Your Audience

1. Interestingness

– Relevant, Meaningful, New

2. Integrity

– Truth, Consistency, Honesty, Accuracy

3. Form

– Beauty, Structure, Appearance

4. Function

– Easiness, Usefulness, Usability, Fit

http://www.informationisbeautiful.net/2009/interesting-easy-beautiful-true/

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Question & Answer

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Michael Hager, MPH MA

Hager Health, LLC

617-359-6074

MichaelHagerNYC@gmail.com