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

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A Guide to Primary Care of People with HIV/AIDS Chapter 17: Quality Improvement 17 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 142 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 17: Quality Improvement 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. As the Project Team conducts its work and gains experience, it will become more independent and assume more responsibility for ongoing measurement, data collection, and implementation of steps toward improvement. DATA COLLECTION 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). Table 17-2: Methods for Obtaining Input from Patients • Suggestion box • Surveys • Focus groups • Consumer advisory board Table 17-3: Sample HIV Quality Indicators Element Of Care HIV staging Antiretroviral therapy Tuberculosis screening OI prophylaxis Gynecological care Syphilis screening Substance abuse education Coordination of care Quality Of Care Indicator CD4 cell count test performed every 4 months Viral load measurement test performed every 4 months ART drug usage for stable and unstable patients Annual PPD testing PCP prophylaxis (CD4 count
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