1917 Clinic, Aryan White Part B & C Grantee

1917 Clinic QM Plan

Page 1

Rev. 2/01/2017

1917 Clinic, aRyan White Part B & C Grantee

Quality Monitoring Plan

QUALITY STATEMENT

Quality Goal - The goal of the UAB 1917 Outpatient AIDS/HIV Clinic’s Quality Management (QM) Program is to ensure that patients receiving care at the clinic receive the highest quality medical and supportive services. To accomplish this goal, the UAB 1917 Outpatient AIDS/HIV Clinic QM program will ensure:

1. Adherence to standards and expectations:

Ensure that direct service medical providers adhere to established practice standards, Public Health Service (PHS) & DHHS Guidelines ( and user expectations to the extent possible;

Relevant Guidelines include but are not limited to the following current DHHS Guidelines:

Adult and Adolescent ARV Guidelines

• Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents HTML
• Printable Version of Full Guideline PDF (2.2 MB)
• Recommendations Only PDF (88.9 KB)
• Tables Only PDF (563 KB)
• Panel Roster PDF (113 KB)
• Financial Disclosures for Panel Members PDF (38.9 KB)
• How to Cite the Guidelines HTML

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How to Cite the Adult and Adolescent Guidelines

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services.Available at accessed [insert date] [insert page number, table number, etc., if applicable]

• Slide Sets HTML

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Slide Sets for Adult/Adolescent Guidelines from the AETC National Resource Center

• Slide Sets for Adult/Adolescent Guidelines from the AETC National Resource Center

• Patient Education Materials HTML

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“Drugs That Fight HIV-1” Brochure

Brochure created by the National Institute of Allergy and Infectious Diseases (NIAID) that features images of Food and Drug Administration (FDA)-approved antiretroviral medications, grouped by drug class.

• “Drugs That Fight HIV-1” Brochure

Adult and Adolescent OI Prevention and Treatment Guidelines

• Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents×

Slide Sets for Adult Opportunistic Infections Guidelines from the AETC National Resource Center

• Slide Sets for Adult Opportunistic Infections Guidelines from the AETC National Resource Center

Perinatal Guidelines

• Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States

Pre-exposure Prophylaxis (PrEP) Guidelines

• Clinical Practice Guideline: Pre-Exposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014
• Clinical Providers’ Supplement: Pre-Exposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014

Occupational Post-exposure Prophylaxis (PEP) Guidelines

• Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis

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Slide Sets for Occupational Post-Exposure Prophylaxis Guidelines from the AETC National Resource Center

• Slide Sets for Occupational Post-Exposure Prophylaxis Guidelines from the AETC National Resource Center

Non-occupational Post-exposure Prophylaxis (nPEP) Guidelines

• Antiretroviral Post-exposure Prophylaxis After Sexual, Injection-Drug Use, or Other Non-occupational Exposure to HIV in the United States

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Slide Sets for Nonoccupational Post-Exposure Prophylaxis Guidelines from the AETC National Resource Center

• Slide Sets for Nonoccupational Post-Exposure Prophylaxis Guidelines from the AETC National Resource Center

Prevention with Persons with HIV (PWP) Guidelines

• Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014

Sexually Transmitted Diseases (STD) Treatment guidelines

Laboratory Testing Guidelines

• Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations
• Suggested Reporting Language for the HIV laboratory Diagnostic Testing Algorithm

Recommendations for Hormonal Contraception

HIV Counseling, Testing, and Referral Guidelines

2. Supportive services focus on access and adherence:

Ensure that critical HIV-related supportive services focus on achieving appropriate access and adherence with HIV care; and

3. Available data are used effectively:

Ensure that available demographic, clinical and health care utilization information, as well as available health outcomes data, are used to monitor the spectrum of HIV-related illnesses and trends in the local epidemic.

Scope of Quality Management Program - The UAB 1917 Outpatient AIDS/HIV Clinic’s QM program covers all services funded through Part B & C of the Ryan White Treatment Modernization Act.

Quality Definitions

• Quality is defined as the degree of excellence of a product or service. In terms of Ryan White, the quality of a service is the degree to which a service meets or exceeds professional standards, guidelines and user’s expectations.

• A Performance Measure is a quantitative tool that provides an indication of the quality of a service or process.

• An Outcome is the benefit or other result (positive or negative) for patients that may occur during or after receiving a service.

• Quality Assurance is a program for the systematic monitoring and evaluation (e.g. through performance measurement) of the various aspects of a service to ensure that standards of quality are being met.

• Quality Improvement refers to conducting activities aimed at improving processes to enhance the quality of care and services.

• The term Quality Management Program encompasses all grantee-specific quality activities, including the formal organizational quality infrastructure (stakeholders and resources), quality assurance and quality improvement activities.

• In this document, the word patient is used to describe an individual who is infected with HIV and who receives health and/or support services at the 1917 Clinic.

QUALITY MODEL

Quality Improvement - The 1917 Clinic ascribes to the Plan–Do–Check–Act Cycle of quality management, also called: PDCA, plan–do–study–act (PDSA) cycle, Deming cycle, Shewhart cycle. Briefly, the plan–do–check–act cycle (Figure 1) is a four-step model for carrying out change. Just as a circle has no end, the PDCA cycle is be repeated again and again for continuous improvement. We use the Plan-Do-Check-Act As a model for continuous improvement when 1) starting a new improvement project, 2) developing a new or improved design of a process, product or service; 3) defining a repetitive work process, 4) planning data collection and analysis in order to verify and prioritize problems or root causes, and 5) implementing any change. The Plan-Do-Check-Act Procedure is simply:

• Plan -- Recognize an opportunity and plan a change.
• Do -- Test the change. Carry out a small-scale study.
• Check -- Review the test, analyze the results and identify what you’ve learned.
• Act -- Take action based on what you learned in the study step: If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

QUALITY INFRASTRUCTURE

Leadership - Leadership for the UAB 1917 Outpatient AIDS/HIV QM program resides within the office of the Director in collaboration with appropriate parties including but not limited to:

Alabama Vaccine Clinic Director,

Clinic Manager,

Consultants (ad-hoc).

Coordinator of Social Services,

Dental Clinic,

Director of IT,

Financial Business Officer II,

IS Project Leader,

Medical Director,

Medical providers, and

Patient Advisory Board

Quality Program Participants& Stakeholder Groups - The QM program activities incorporate 1917 Clinic staff members, Health Resources and Services Administration (HRSA) HIV Bureau quality indicators, and patient involvement. Group members play an important role in identifying service needs and areas for service improvement. The role of each of these stakeholders is described.

1. 1917 Clinic Leadership Council – maintain a proactive quality focus to promote high level patient outcomes through 1) QM goal setting, 2) linkages to committees within the UAB Health System enterprise, i.e. Department of Medicine’s Clinical Practice Committee & TKC External Clinic group; IMPACT Clinic Expert User Group Meeting, and 3) on-going quality-education/awareness initiatives.

Membership - Director (Chairperson), Medical Director, CFAR Director, 1917 Clinic Manager, 1917 Clinic Cohort Coordinator, 1917 Clinic IS Project Leader, IT Director, 1917 Dental Clinic Director, 1917 Research Clinic Nurse Manager, CFAR Director, CFAR Director of the Behavior Core, CFAR Director of the Clinical Core, CFAR Business Officer.

1. 1917 Clinic Staff -The clinic staff members are primarily responsible for QM activities as described herein (infra).

• As the Quality Coordinator, the Director provides 1) develops and maintains annual quality plan, 2) provides oversight and guidance to staff regarding daily responsibilities and those related to quality management, 3) reviews the QM program, including QM plans and quality improvement activities, 4) monitors utilization of grant-funded services by coordinating data collection and compiling reports (e.g. quarterly CQIperformance reports), 5) supports ongoing QM projects for Part B activities, 6) develops and implements outcomes for Part B, and 7) provides QM training and mentorship to other members of the QM Team.

• Medical Director: 1)Serves as supporting resource and coach for quality programs and clinic staff, including the subspecialty clinics. 2)Utilizes expertise and knowledge of quality principles and tools to promulgate quality program strategies. Provides direction and assistance in implementation of programs. 3) Assures the implementation of quality improvements and quality tracking reports. Assists with oversight of all major quality program areas and coordinates and identifies requirements for specific area expertise (patient safety, core measures, infection control, accreditation/regulatory compliance, quality assessment and performance improvement program, medical staff professional practice review, etc). 4) Assists on implementation of quality related deficiency action plans.

Coordinator of Social Services: 1) conducts monitoring activities for Part B quality activities by coordinating data collection and compiling reports (e.g. quarterly QM performance reports), 2) works with Quality Coordinator to develop and monitor performance measures related to case management, 3) ensures adherence to state HIV case management service standards through annual chart reviews and monitoring of performance measures, and 4) develops and implements policies and procedures to improve the overall delivery of case management services.

• Nutritionists: monitors adherence to nutritional standards, including but not limited to BMI screening and follow-up plan documentation.

• Women’s health advance practice nurse practitioner: monitors adherence to care standards for pregnant women, contraceptive care and cervical PAP screening.

•Research Informatics Services Center (RISC) Program Manager: monitors suicide risk.

• Linkage & Retention in Care Program Director: monitors adherence to new patient visits and retention in care.

• Data Analyst–1) provides general analytical support to the QM program and 2) completes monthly and quarterly reports.

• Employees - Job descriptions include a quality component.

IV. Health Resources and Services Administration - HRSA’s HIV/AIDS Bureau (HAB) is committed to improving the quality of care and services and ultimately the quality of life for PLWH/A. To support 1917 Clinic quality assurance and QM activities, HRSA provides:

• Technical assistance

• On-line training and resources

• HAB Performance Measures for Adult/Adolescent Patients (Core medical measures released; draft measures for systems, oral health, medical case management and ADAP recently released for comment)

• Site visits

• Program and fiscal monitoring through various reporting requirements

1. Patients -Patient input is a critical piece to delivering high quality services. Patient input is obtained through the grievance process, patient satisfaction surveys and participation on Patient Advisory Board. In addition, information feedback is obtained by patients through ongoing communication with providers and from patient-employees.

1. UAHSF – integration of 1917 Clinic QM initiatives through the office of the UAHSF Chief Quality/Patient Safety Officer.

Resources -Approximately 3% of the total Ryan White budget is allocated for Planning & Evaluation and Quality Management activities. These funds cover, in part, the activities of the Quality Coordinator and Systems Analyst. Funds are also budgeted for travel to RW Clinical Updates and all Title Meetings. All clinic quality activities are covered by the Ryan White Part C funding.

Quality Management resources provided by the following organizations are consulted frequently:

• Health Resources Services Administration HIV/AIDS Bureau (

• National Quality Academy (

• Institute for Healthcare Improvement (

• New York State Department of Health AIDS Institute (

• Target Center: Technical Assistance for the Ryan White Community (

QUALITY GOALS & ACTIVITIES

The primary QM goals are to ensure that:

• Funded services adhere to PHS/DHHS guidelines, established clinical practice, and user expectations;

• Program improvement includes supportive services linked to access and adherence to medical care; and

• Demographic, clinical and utilization data are used to evaluate and address characteristics of the local epidemic.

Annual Utilization/Quality Data (Ryan White Data Report- Client level reporting, 2017)

• Review end-of-year clinic report

• Approve final report prior to uploading to HRSA

• Report end-of-year data to HRSA, via the ADPH

• Make corrections, as identified by Ryan White Coordinator

Performance Measurements – Ongoing quality assurance and quality management activities are summarized in Table 1. These indicators are consistent with and representative of those endorsed by “HIVQUAL” (Table 2). The process for monitoring these nationally recognized clinical indicators involves the systems analyst performing quarterly analysis that surveys the entire patient data base. The preliminary data/findings, along with a listing of all outliers are sent to the QM Coordinator who reviews the data and each instance of discrepancy. The QM manager monitors the data for trends that might negatively impact patient outcomes and simultaneously works with individual providers to reconcile non-adherence to standards of care. Individual providers are notified when a discrepancy is identified and consulted as to how the provider wants to proceed in the care of the individualized patient. (Sometimes it is necessary in the practice of medicine to develop plans of care that may not adhere to nationally accepted guidelines.) A Continuous Quality Improvement segment is incorporated into the medical director‘s quarterly mandatory provider meeting. Data are used as an impetus for improvement and a way to monitor progress to an identified goal.

1917 Clinic QM Plan

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Rev. 2/01/2017

• Table 2: HIVQUAL National Core Indicators

• Adherence Assessment

• Anorectal Exam and Anal Pap Smear

• ARV Therapy Management

• Baseline Resistance Test

• Clinical Visits

• Dental Care

• Gynecology Care

• Health Literacy Screening

• Hepatitis C (HCV) Screening

• HIV Monitoring

• HIV Specialist Care

• Lipid Screening

• MAC Prophylaxis

• Mental Health Screening

• PCP Prophylaxis

• Pneumococcal Vaccination

• Prevention Education

• STI Management

• Substance Use Screening

• TB Screening

• Tobacco Use Screening

1917 Clinic QM Plan

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Rev. 2/01/2017

EVALUATION

Impromptu, quarterly and annual evaluation is conducted to determine if Quality Goals and performance measures are achieved.

1. Adherence to standards and expectations (see performance indicators): Ensure that direct service medical providers adhere to established practice standards, DHHS Guidelines and user expectations to the extent possible;

2. Supportive services focus on access and adherence (based on RSR statistics): Ensure that critical HIV-related supportive services focus on achieving appropriate access and adherence with HIV care; and

3. Available data are used effectively (measures to insure data integrity are working): Ensure that available demographic, clinical and health care utilization information, as well as available health outcomes data, are used to monitor the spectrum/continuum of HIV-related illnesses and trends in the local epidemic.

Clinical and non-clinical performance measures areevaluated quarterly for trends in outcomes andannually by clinic leadership for their appropriateness of continued monitoring.

1917 Clinic QM Plan

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Rev. 2/01/2017

CAPACITY BUILDING

• Assessment of the Quality Improvement capacity of providers is assessed by the degree of involvement in QM activities (see publications, infra).
• Assess QM training activities.
• Assess the feedback mechanisms to providers. Determine if a “Continuous Quality Improvement” segment was incorporated into the medical director’s quarterly mandatory “provider meeting.”

PROCESS TO UPDATE QM PLAN

The QM Coordinator will initiate an annual review of plan immediately following RW EIS Part C grant submission. However, impromptu revision can be made to address newly identified areas of concern.

The Director and Medical Director approve the annually revised plan.

COMMUNICATIONS

Dissemination of findings – The principle manner to communicate provider feedback is twofold: 1) when a deviation from the guideline is detected and 2) during the“Continuous Quality Improvement” segmentsof themonthly staff meeting and the medical director’s quarterly mandatory “provider meeting.”

QM IMPLEMENTATION

Most recent REVISION:2/01/2017

QM Program activities in 2015, 2016& 2017 YTD (2/01/2017)

• Development and implementation of a plan for increasing safety in the workplace
• This multifaceted activity is being implemented in response to multiple potentially violent incidents (e.g. implied and explicit threatening behavior by patients toward 1917 Clinic providers, staff and visitors; firearms and other weapons brought into clinic, disruptive and disrespectful visitor behavior at the pharmacy requiring law enforcement notification)
• In-service education: “Safety and De-escalation” by UAB Police to provide 1917 Clinic personnel with strategies related to:
• De-escalation of “upset” individuals
• When & how to call for the resources of UAB Police
• Response to a situation involving an active shooter
• Adaptation of UAB Hospital “Code Q” policy for use in the 1917 Clinic.
• Review commonly recognized strategies for creating a safe and caring work environment – nonviolent crisis intervention.
• Magnometer proposed, approved and ordered.