A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 17: Quality Improvement
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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 wellestablished
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.
Table 17-1: Core Principles of
Quality Improvement
• Focus on the customer: improvement activities result in
improved patient health
• Measurement: collect and use data to improve care
• Emphasis on systems of care: improve processes that link to
desired outcomes
• Involvement of participants: encourage direct participation
in teams by those individuals who implement the processes
being evaluated
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
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau