A Guide To Primary Care For People With HIV/AIDS, 2004 edition< Previous | Home | Next >
Chapter
17
Overview TOP
An open letter to clinic directors: You may have dismissed quality improvement from your agenda for many reasons. You may think it is someone else's job, or it's a lot of extra work with no benefit, or think that you've already got a quality program in place. You may think that your current system of monitoring the charts in your clinic and giving feedback to the providers who aren't doing the right thing is a quality improvement (QI) program. You may also think that your clinic is doing a fantastic job and that you don't need to monitor its quality. Here's why it's worth investing the time and effort:
This chapter describes how your clinic can develop, implement, and maintain a QI Program and what your role in it might be, whether part of a QI Project Team, the Quality Committee, or simply a customer of the performance measurement and quality improvement processes. What is Quality Improvement (QI)? Quality improvement (QI) includes regular measurement of care processes and outcomes to analyze processes and systems of care. It involves implementation of solutions to improve care and monitor their effectiveness with the goal of achieving optimal health outcomes for patients. Ongoing cycles of change and remeasurement are implemented to test and try different ideas to determine which result in improved care. QI activities in clinics can range from a single team focusing on improving one aspect of care to a comprehensive QI program with many teams working on a wide variety of improvement projects, with a well-established plan and an oversight committee. The methods of QI are based on core principles that are readily translated into a practical approach and integrated into the clinical care delivery system (see Table 17-1). Successful implementation of QI involves actions at 2 different levels: the QI activities and the HIV program processes that provide the structural backbone for them. This section will articulate the core principles and describe activities that can be easily adapted into the HIV ambulatory care setting to implement a sustainable QI program.
Descriptions of the chronic care model that serves as an important application of QI principles to HIV care can be found in Chapter 1, Figure 1-1, and Chapter 18, the section on Integrating HIV Specialty into Practice. A training manual developed from an HIV/AIDS collaborative is available from the Institute for Healthcare Improvement (see Suggested Resources). Why aren't chart audits sufficient for QI - Why can't management just conduct QI? Measurement alone is not sufficient to improve quality. A common pitfall in implementing QI programs is to rely solely upon performance data, the medical or program director's interpretation of it, and one person's decisions about how to make changes. Successful improvements most often result when staff members from the systems being assessed work together in teams. When they are engaged in the process, they are more likely to generate ideas to try and to accept changes. Which personnel should be involved in QI? The size of the clinic will determine who participates in quality-of-care activities. In small HIV clinics with a primary care provider, case manager, nurse, and support staff, most of the staff are involved in all aspects of QI work. Larger institutions usually establish an HIV Quality Committee that includes senior management staff of the HIV clinic, designated QI staff if there are any, and other key players who work in the clinic. A member of this committee represents the group in the agency-wide quality committee. The Quality Committee identifies the priorities for improvement or agrees to use priorities identified by staff or patients in the clinic. The Quality Committee also charters improvement teams, identifying potential members who are key stakeholders in the process under investigation or their representatives. Who should be on the teams? Teams are formed to address the specific care processes or systems undergoing improvement. Team members should be selected to represent the different functions involved in these processes or to represent the components of the system under focus. The size of a team varies according to the size of the clinic and the process under study. In small clinics, the few dedicated HIV program staff may constitute the project teams, with added representation from different departments as needed, such as from the lab, or from other medical disciplines. In larger clinics, teams often include 6-10 members. Membership should include representatives from the different groups in the clinic who are involved in the care process. In addition to the clinical and case management representatives, scheduling clerks and medical records staff are often important representatives, especially when followup appointments and documentation are important components of the care process or have been identified as areas that need to be improved. What are the responsibilities of the team? Teams are expected
to identify areas of change, implement pilots to test the change,
review data assessing the change, and ultimately make recommendations
about improvements. Team meetings should be kept flexible and adapt
to the working environment of the clinic as much as possible, although
a few specific guidelines will help keep things running smoothly.
These include designating a leader for the team, developing clear
and specific aims and goals, and ensuring that a clear line of accountability
is defined pointing back up to the Quality Committee. Sometimes,
short impromptu meetings keep the momentum of the project going
and enable rapid decisionmaking based on results as soon as they
become available. Data Collection TOP How do you select which components of care should be measured? Indicators are measurable aspects of care that evaluate the extent to which a facility provides a certain element of care. Indicators should be based on standards or guidelines, meet the primary goals of QI, and reflect priorities specific to the community and the clinic. For example, in HIV clinics where the population includes a large number of women, indicators may include rates of routine Pap smears, rates of preconception counseling, or other aspects of care specific to women. In clinics that care for a high volume of patients with severe immunosuppression and advanced HIV disease, indicators may include rates of prophylaxis for specific opportunistic infections, such as PCP and MAC. Some indicators should be selected by soliciting input from patients who attend the clinic (see Table 17-2). Staff members also often know what aspects of care would benefit from being measured and improved and should be consulted to determine priorities. If routine data collection systems already exist in the clinic, data should be reviewed to determine which components of care would be prime candidates for improvement (see Table 17-3 for sample indicators).
Once the aspect of care has been selected, how do you develop and measure the indicators? Three major activities constitute the process of indicator development:
The measurement population is defined by determining the location of care being studied, whether both men and women are eligible, the applicability of the indicator to different age groups, whether any clinical conditions are necessary to determine whether the indicator is applicable, and whether the patient must have been in treatment or visited the clinic more than once. After defining the population, the measure needs to be defined. For each measure, specific criteria must be developed to define the "yes" response and the "no" response (see Table 17-4). Often this involves deciding during which time period an activity has been performed. For example, an indicator measuring viral load monitoring must include the frequency with which that test should be performed. One simple way to construct this measure would be to ask "Was viral load measured within the last 4 months?"
The data collection plan includes determining the source of information, such as whether medical records or an electronic database will be used, how the data will be recorded, who will record the data, and how a sample will be selected. A representative sample will allow inferences to be made about the clinic population based on observations of the smaller sample. Some form of random sampling should be used, either from a random numbers table, or a selection of every nth record from the list of eligible patients. A common pitfall at this point is to think of the measurement sample as a research project. For the purposes of QI, a sample just needs to be current, representative, and readily obtained (ie, sample size calculations and the achievement of statistically significant results are not necessary). Should you measure only one indicator at a time? Definitely not. Several indicators should be measured simultaneously, whether abstracted from medical records or analyzed through administrative databases. Indicators reflecting different aspects of patient management should be selected, as well as those involving different populations. Indicators should also be selected to evaluate different components of the health care system, such as the different components of the chronic disease model. How should you analyze and display data? Data should be reviewed and distributed to all members of the team and others involved in the care process under evaluation. Whenever possible, data should be displayed in graphic format. Once data from several time periods have been collected (eg, rates of patients with viral load performed every 4 months collected in 2 different time periods), a simple line graph (run chart) can be constructed with each point representing a performance rate (percentage) for a given period of time. This is usually the simplest and most effective way to show performance data (see Figure 17-1). Figure 17-1: Sample Run Chart: Percentage of Patients PPD Tested, by Month 
How does improvement occur? Once the data have been reviewed by the team and the process for improvement identified, the next step is to decide where opportunities for improvement exist. This process is described as the PDSA (Plan-Do-Study-Act) or PDCA (Plan-Do-Check-Act) cycle (see Figure 17-2). The first step is to investigate this care process in greater detail. Several techniques are often used to accomplish this goal. The simplest is brainstorming, in which individuals offer their suggestions for which processes are the best candidates for change. Another easy method is flowcharting, in which the group breaks down the process into its components to identify how it is coordinated and how its parts fit together. Then, the areas that would be most likely to benefit from improvement are selected for change (see Figure 17-3). Figure 17-2. Plan-Do-Study-Act Cycle  Once a change in a particular step of the process has been selected, a pilot test of the change can be quickly implemented and evaluated. A limited implementation of the proposed change can be tested - perhaps with just the next few patients, or those attending on the next day, or those seen by a particular clinician. If the pilot does not work, another change can be selected and quickly implemented. If the change is feasible and improvement is noted, then the change can be adopted more widely, before formal remeasurement occurs, and a regular period of remeasurement adopted. If the change was not successful, then another one can be chosen and tested. What systems need to be established to support QI? The key to sustaining QI in the clinic is development of an infrastructure that supports ongoing QI activities. The central components of this infrastructure include:
Figure 17-3. Sample Flow Chart 
The regular, ongoing work of the QI Committee, supported by the clinic's leadership, constitutes the backbone of the infrastructure that supports ongoing QI activities. The committee oversees the dynamic process of planning, implementation, and evaluation that involves:
These activities contribute to sustaining the QI Program and its activities in the clinic. Will improvements last? Sustainability is probably the biggest challenge that clinics face in the field of QI. All too often, improvements do not last once initial projects are completed, because the structure and culture to support QI is not present or is not supported. The challenge of sustainability is therefore two-fold - not only to maintain the successes of QI work and its clinical outcomes, but also to maintain the systems of QI and to keep the QI program vital. By asking questions about how care systems can be improved and how QI activities are progressing, clinicians play an important role in both catalyzing and supporting QI activities. What are the key components of a quality plan? The key elements of a quality plan include a quality statement that describes the purpose and goals of the QI program, priorities of the program, a description of the organizational systems needed to implement the program, including committee structure and functions, definitions of accountability, roles and responsibilities, the process for obtaining consumer input, core measures, data collection processes, and a description of how the plan will be evaluated.
References TOP Institute for Healthcare Improvement. HIV/AIDS Bureau Collaborations: Improving Care for People Living with HIV/AIDS Disease. Boston: Institute for Healthcare Improvement; 2002. Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol.1. Washington: National Academy Press; 1990. Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy Press; 2001. Institute of Medicine. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC:The National Academies Press; 2004. New York State Department of Health AIDS Institute. HIVQUAL Group Learning Guide: Interactive Quality Improvement Exercises for HIV Health Care Providers. New York, NY: New York State Department of Health AIDS Institute. New York State Department of Health AIDS Institute. Measuring Clinical Performance: A Guide for HIV Health Care Providers. New York, NY: New York State Department of Health AIDS Institute; April 2002. |
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