Section 4

Processes & Projects

Section 1

Quality Statement

Section 2

Quality Infrastructur

e

Section 3

Performance Measures &

Annual Goals

Section 7

Communicating Reports & Initiatives

Section 6

Stakeholder Participation

Section 5

Yearly Program Activities

Section 8

Evaluation

Writing a Quality

Management Plan

GlossaryCredits/Contact

Quality Statement

Description

Additional Resources

Tips and Tools

Example

The quality plan begins with a quality statement. It should include a brief

purpose statement describing the end goal of your HIV quality program and a

shared vision to which all other activities are directed.

Assume an ideal world and ask yourself, “What do we want to be for our

clients and our community?”

Quality Statement

Description

Additional Resources

Tips and Tools

Example

Quality statements should:

• Be brief

• Be visionary

• Include internal and external expectations

• Make references to Ryan White legislative requirements for quality

management

Quality Statement

Description

Additional Resources

Tips and Tools

Example

Click to open

Description

Additional Resources

Tips and Tools

Example

Additional Resources for Writing QM Plans

• National Quality Center (NQC) Quality Academy:

The Quality Management Plan (lesson 5)

• NQC Resources:

How to develop and update written quality management plans

• Health Resources and Services Administration:

Developing and implementing a QI plan

Quality Statement

Quality Infrastructur

e

Description

Additional Resources

Tips and Tools

Example

Quality infrastructure includes the critical aspects of funded services.

These should be relevant, measurable, and improvable. If available, you will

want to include:

• Leadership: those responsible for QM initiatives

• Quality committee structure: those who serves on the QM committee

as chair and or as coordinators

• Standards: the framework and expectations for the QM program

• Roles and responsibilities: key persons, organizations, major

stakeholders

• Resources: resources available/used by the QM program

• Capacity building: how quality is being integrated into all

functions/aspects of the program

Quality Infrastructur

e

Description

Additional Resources

Tips and Tools

Example

The quality infrastructure section of the quality plan should include:

• 3 – 5 pages

• Job Functions

• All stakeholders and responsibilities

• Linkages/networks

Quality Infrastructur

e

Description

Additional Resources

Tips and Tools

Example

Click to open

Description

Additional Resources

Tips and ToolsExample

Quality Infrastructur

e

Additional Resources for Developing QM Infrastructure

• National Quality Center (NQC) Quality Academy: QM infrastructure—how to

establish a quality management committee

• NQC Quality Academy

: Integrating quality into all aspects of an organization

• NQC Quality Academy: Systems thinking

• Health Resources and Services Administration:

Redesigning a system of care to promote QI

Performance Measures &

Annual Goals

Description

Additional Resources

Tips and Tools

Example

Performance measures is the system used to track desired client

outcomes and the program’s progress towards achieving those outcomes.

These outcomes should be as good as or better than national treatment

standards.

Annual goals are drawn from the list of performance measures. Key

stakeholders decide which performance measures to focus upon improving

for the year.

Performance Measures &

Annual Goals

Description

Additional Resources

Tips and Tools

Example

Performance Measures:

• Identify critical aspects of care and services provided, and

• Develop indicators, and measure how well the program is progressing

towards achieving desired outcomes in care and service

• Choose measures from reputable sources (such as HRSA, CDC, HCS, etc.)

• Obtain data from multiple sources to ensure accurate reporting

Annual goals:

• Key stakeholders should be responsible for choosing a few goals each year

(no more than 5)

• Benchmarks should be set for each chosen performance measure

• Improvement activities for the year should be designed to improve chosen

performance measures

Performance Measures &

Annual Goals

Description

Additional Resources

Tips and ToolsExample

Click to open

Description

Additional Resources

Tips and ToolsExample

Additional Resources for Creating Measures and Annual Goals

• National Quality Center (NQC) Quality Academy:

How to develop ADAP quality indicators

• NQC Resources: Measuring performance in HIV care—how to collect

performance data and examples of HIV quality indicators

• NQC Resources: Measuring clinical performance—a guide for HIV health

care providers

• NQC Resources: Data collection tools

• Institute for Healthcare Improvement:

Science of improvement—establishing measures

• Health Resources and Services Administration (HRSA):

Performance management and measurement

• HRSA: Management data for performance improvement

Performance Measures &

Annual Goals

Processes & Projects

Description

Additional Resources

Tips and ToolsExample

Your QM Plan should explain the processes you use for selecting,

documenting and measuring improvement projects.

Quality improvement (QI) processes refer to the criteria for selecting

improvement projects, documenting projects/status/results, tools and

techniques used for improvement activities (i.e., Lean, PDSA, Model of

Improvement, etc.), feedback and evaluation of projects.

QI projects are systematic and documented activities designed to improve

programmatic processes and/or outcomes of processes.

Processes & Projects

QI processes

• Describe the process for how you choose and prioritize projects

• Describe how you monitor and document your projects

• Describe how you ensure your projects can be linked to specific

performance measures, annual goals, strategic goals or the mission

statement

• Describe what quality improvement tools you use for projects

QI activities

• List program activities and how they were selected

• Describe your improvement projects, and what project teams and quality

improvement tools you will use

Description

Additional Resources

Tips and Tools

Example

Processes & Projects

Description

Additional Resources

Tips and ToolsExample

Click to open

Additional Resources for QM Processes and Projects

• National Quality Center (NQC) Quality Resources:

Conducting quality improvement activities—essentials to implementing

quality improvement projects

• NQC Quality Resources: The improvement guide

• The LeanOhio information kit

• The Institute for Healthcare Improvement: Model of improvement

Description

Additional Resources

Tips and ToolsExample

Processes & Projects

Yearly Program Activities

Description

Additional Resources

Tips and Tools

Example

Yearly program activities are improvement projects designed to improve the

program (and ultimately improve upon client outcomes). Activities and

measures are chosen based on pre-determined criteria. Improvement projects

must be measurable and align with the agency mission.

Yearly Program Activities

• List your criteria for choosing projects, such as financial benefits,

efficiency, etc. and who will be involved in prioritizing projects

• Create SMART objectives: specific, measurable, attainable, relevant, and

timely

• Document your process for tracking projects

• Explain the processes you will use and how your objectives will be linked to

specific performance measures

• Include the who, when, and how about each activity

• Determine how you will be reporting your measures to key stakeholders

Description

Additional Resources

Tips and Tools

Example

Yearly Program Activities

Description

Additional Resources

Tips and Tools

Example

Click to open

Additional Resources

• Health Resources and Services Administration :

Readiness assessment & developing project aims

• National Quality Center: QM program assessment tools

Description

Additional Resources

Tips and Tools

Example

Yearly Program Activities

Stakeholder Participation

Description

Additional Resources

Tips and ToolsExample

Stakeholders refer to anyone who has a concern or interest in something,

and who may be affected in some way by your RW QM program actions,

objectives, or policies. Address how different stakeholders are involved in

your QM program:

• How are internal and external stakeholders involved in/impacted by your

program? (impacts may be negative or positive.)

• How are your quality improvement activities communicated to them?

• What opportunities are you providing for them to learn about quality?

Stakeholder Participation

• Create a chart that lists internal and external stakeholders and their

functions/responsibilities

• Include:

• Providers

• Consumers

• Sub-grantees

• Other Ryan White CARE Act Parts

• Resources impacted by QM program (e.g. databases managed by IT,

transportation managed by DAS, etc.)

• List proposed training opportunities for stakeholders

Description

Additional Resources

Tips and Tools

Example

Stakeholder Participation

Description

Additional Resources

Tips and ToolsExample

Click to open

Additional Resources for Engaging Stakeholders

• National Quality Center Quality Academy:

Engaging staff and consumers in QI work

• Project Management Institute: Engaging stakeholders for project success

• Health Resources and Services Administration: Improvement teams

Description

Additional Resources

Tips and ToolsExample

Stakeholder Participation

Communicating Reports & Initiatives

Description

Additional Resources

Tips and ToolsExample

Integrating QI into an organization and culture requires communication with

all stakeholders (internal and external) about successes and updates.

Storyboards are a great tool for sharing this information. Your successes

become their successes and increases both QI visibility and perceived value

within the organization.

Communicating Reports & Initiatives

Compile a list of your stakeholders, important information, and important

dates, then create a chart with the following columns:

• What you will be communicating (e.g. templates, data, reports, etc.)

• Who will be communicating it (supervisor, chairperson, QI team lead, etc.)

• How you will communicate it (e.g. electronic, mail, teleconference, etc.)

• To whom you will communicate the information (agency, committee, etc.)

• When (or how often) you will communicate it

Description

Additional Resources

Tips and Tools

Example

Communicating Reports & Initiatives

Description

Additional Resources

Tips and ToolsExample

Click to open

Additional Resources

• Healthcare Information & Management Systems Society/Robert Wood

Johnson Foundation:

Lessons learned in public reporting: deciding what to report

• Quality Assurance & Performance Improvement: Storyboard guide for PIPs

(performance improvement project)

Description

Additional Resources

Tips and ToolsExample

Communicating Reports & Initiatives

Evaluation

Description

Additional Resources

Tips and ToolsExample

The evaluation explains how your QM program will assess it’s own

performance in terms of:

• Infrastructure: how effective is your existing infrastructure? Can it be

improved?

• quality improvement activities: were goals met? If so, how effective were

your activities?

• Outcome performance measures: were your measures appropriate for

assessing clinical and non-clinical HIV care? Were goals met? Were

stakeholders informed? Was training provided?

• Improvement: how can your QM program improve upon the prior year’s

results?

Evaluation

• Explain who is performing your QM program’s evaluation and when

• Compare your annual quality goals with your year-end results

• Use your findings to plan next year’s activities; learn and respond from

your past performance

• Routinely use organizational assessment tools like those provided by the

National Quality Center

Description

Additional Resources

Tips and Tools

Example

Evaluation

Description

Additional Resources

Tips and ToolsExample

Click to open

Additional Resources for evaluating your QM program

• National Quality Center Quality Academy: QM program assessment tools

• Centers for Disease Control: A framework for program evaluation

Description

Additional Resources

Tips and ToolsExample

Evaluation

Software

Microsoft PowerPoint

2013

Software

Instructional DesignerSponsor

Credits & Contact

Contact information

Instructional Designer

Jamie L. Perez, M.S.,

M.Ed.Sponsor

Ohio Department of HealthHIV Care Services Section246 North High Street, Columbus, OH 43215http://www.odh.ohio.gov/hcs

Contact Informationhcs@odh.ohio.gov614-466-6374

Date availableMay 2015