5. Quality Management
HIV-related morbidity and mortality dropped dramatically in the latter 1990’s due to advances in HIV/AIDS treatment. However, reductions have been unevenly distributed across HIV-infected populations due to such factors as unequal access to care and variable quality of services (e.g., treatment regimens, client support, provider skills). Quality management programs are designed to bring these benefits to all clients by improving the quality of care of all CARE Act services.
Quality management programs should:
Quality management is central to addressing the following key CARE Act themes:
Legislative Background TOP
Section 2612(d) of the CARE Act requires that each State “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.”
Section 2612 also provides for funding of quality management activities. It states that, in addition to the percent of funding allocated for administrative costs, the State may use for quality management activities not more than the less of 5 percent of amounts received under the grant; or $3,000,000.
HAB/DSS Expectations TOP
The CARE Act places major emphasis on enhancing the quality of care for persons living with HIV disease. The complexity of HIV care and the Act’s commitment to equal access to quality care for all HIV-positive individuals require systematic efforts to ensure that CARE Act services are delivered effectively.
Definition of Quality
Quality is defined by HAB/DSS as the degree to which a health or social service meets or exceeds established professional standards and user expectations. In order to continuously improve systems of care for individuals and populations, evaluation of the quality of care should consider:
Purposes of Quality Management
According to the Managers’ Statement in the CARE Act Amendments of 2000, quality management programs are expected to accomplish three related purposes:
A successful quality management program should:
Coordination of Quality Management with Program Support Spending
In deciding what activities to undertake, Title II grantees should coordinate their quality management efforts with any program evaluation and quality assurance activities currently funded under Program Support.
Quality management activities may include but are not limited to:
Program Support funds are used for CARE Act expenditures that are not service-oriented or administrative in nature. In clinical quality programs, supported activities may include, but are not limited to:
DSS will monitor grantee compliance with quality management requirements through questions in application guidances, progress reports, and site visits. States will sign assurances in their annual applications attesting that appropriate quality management programs are in place.
Quality Management Methods TOP
A number of tested concepts can be used in Title II quality management program efforts. They include quality assurance, quality improvement, continuous quality improvement (CQI), and outcomes evaluation. Continuous quality improvement and quality assurance are particularly relevant because of their focus on managing program quality. Each is described below.
Continuous Quality Improvement (CQI)
CQI is an ongoing process that involves service providers in ongoing activities to continuously improve service delivery. Activities include monitoring and evaluating inputs, processes, outputs, and outcomes. In contrast to quality assurance, which focuses on identifying and solving problems, CQI seeks to prevent problems and to maximize the quality of care. Steps in the CQI process include the following:
1. Plan – Identify problems (including their components—not just the big picture) and then plan strategies/tests that might result in improvements.
2. Do – Use strategies/tests that are designed to address problems.
3. Study – Collect and analyze data to see if strategies have resulted in improvements.
4. Act – If the strategies are effective, make them an ongoing activity. If they are not effective, return to the Plan stage. Use collected data to identify new ways to address problems.
Quality Assurance (QA)
Quality Assurance involves identifying problems in service delivery, designing activities to overcome these problems, and following up to ensure that no new problems have developed and that corrective actions have been effective. The emphasis is on meeting minimum standards of care.
Evaluation and CQI
Evaluation and CQI are closely related but nonetheless different. CQI is a process to continuously improve services and outcomes. Evaluation focuses on collecting information about programs (i.e., characteristics, activities, outcomes) to determine whether objectives were met and to make program changes to improve services and outcomes.
Criteria Used to Assess Quality
Standards or targets can be used to determine whether a program’s implementation and/or outcomes are successful. Listed below are examples of criteria that can be used to evaluate service delivery processes and/or outcomes:
Measuring Clinical Quality
Quality management can provide measures of the clinical, administrative, and fiscal components of a program. Examples of measurable clinical goals and outcomes include the following:
HRSA/HAB Quality of Care Activities TOP
The following resources supported by HRSA provide models for use in developing quality management programs.
HIVQUAL. This software-based CQI program is an approach to improving quality of care for PLWH. It focuses on systems improvement, information management, and performance management. Project components include HIVQUAL quality monitoring software along with quality improvement consultation aimed at building knowledge, skills, and capacity around quality systems in provider organizations. HIVQUAL was developed by the New York State Department of Health AIDS Institute for the Ryan White Title III program. For further information, contact the HAB Division of Community Based Programs at 301-443-9051.
Primary Care Assessment Tool (PCAT). This site visit protocol developed for CARE Act programs funded under Title III is used to evaluate the clinical, fiscal, administrative, and support services of CARE Act grantees. A quality improvement component is included in the clinical section. Download PCAT.
Special Projects of National Significance (SPNS). HAB’s SPNS grants support the development of innovative demonstration projects that respond to the challenge of HIV/AIDS service provision to underserved and vulnerable populations. Select SPNS projects address quality of care. Others SPNS projects focus on such related topics as improving integrated care systems and evaluation of care systems.
HAB’s Quality Initiative includes a series of “rapid learning strategies,” which are training sessions for CARE Act grantees. They are designed to accelerate the pace of quality improvement activities. For further information, contact HAB Division of Training and Technical Assistance (HAB/DTTA), 301-443-6366, and the Institute for Healthcare Improvement, HIV/AIDS Breakthrough Series Collaborative, 135 Francis Street, Boston, MA 02215, 617-754-4821.
The Center for HIV Quality Care conducts research on issues including appropriate standards of HIV care, including ancillary services at all stages of illness, and the cost of HIV care that corresponds to these standards of care. The effort is to create a national picture of Medicaid managed care benefit packages and capitation rates. For further information, contact the Infectious Diseases Society of America, 66 Canal Center Plaza, Suite 600, Alexandria, VA 22314, 703-299-0204, or by email.
Outcomes Evaluation and the Logic Model. HAB has developed several outcomes evaluation guides. These guides provide a framework for outcomes evaluation and in some cases sample outcome measures. These guides either use a Logic Model or describe such a model as one option for outcomes evaluation. The Logic Model format was developed by United Way of America and is being used by an increasing number of CARE Act grantees. The model provides a clear, step-by-step process for outcomes evaluation and helps clarify the difference between outputs and outcomes. It also differentiates initial, intermediate, and longer-term outcomes. The following guides are available through the HAB website or may be obtained from HAB:
HIV/AIDS Evaluation Monograph Series. HAB’s Office of Science and Epidemiology has developed a series of publications to assist CARE Act grantees in designing and implementing evaluation studies. These monograph series are available through the HAB website TA Library or the HRSA Information Center at 888-ASK-HRSA. They include:
Agency for Health Research and Quality. AHRQ is the lead Department of Health and Human Services (HHS) agency supporting research to improve quality of care, reduce costs, and increase access to essential services.
The National Quality Measures Clearinghouse (NQMC). Under development by ECRI through a contract from AHRQ, the National Quality Measures Clearinghouse is designed to provide an Internet-based resource of evidence-based health care quality measures. Using a standardized language and common platform, the NQMC links two well-established AHRQ resources:
The NQMC will allow users to search these databases in combination and receive a report that lists evidence-based quality measures and guidelines.
National Forum for Quality Measurement and Reporting. This private, nonprofit organization has responsibility for the creation of comprehensive quality measures that are consistent with national aims for quality improvement.
U.S. Consumer Gateway Health Care Quality Page. Provided are information and links to numerous aspects of health care quality, including selecting a plan, purchasing health care services, and privacy.
HRSA Center for Quality: Links Listed here are organizations that deal with quality care as well as other public health issues.
Business and Higher Education Developed CQI and Total Quality Management (TQM) Information. Business-focused CQI information can often be applied to the health care setting and used to advance the quality of HIV/AIDS services. Many business-oriented websites require a fee or membership to access CQI and TQM information. See the following:
Quality Assurance Reporting Requirements, A Report on Managed Care Performance. This report is the New York State Department of Health’s annual publication of quality, access, utilization, and descriptive data collected from managed care plans licensed to operate in New York State. The report is made available to managed care plans, providers, purchasers, and consumers as part of the Department’s overall strategy to improve the quality of care provided to New Yorkers by managed care plans and to increase accountability to the public.
Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). “Quality of Care: HRSA/HAB Resources.”
HRSA, HIV/AIDS Bureau. “Quality Assurance and Improvement,” CARE Act National Technical Assistance Call. Rockville, MD: U.S. Department of Health and Human Services, 1995.
HRSA, HIV/AIDS Bureau. “Use of Funds for Quality Management Programs,” Title I Reauthorization Letter #4, 2001.