QUALITY CABS

Quality CAB Guide

The purpose of this guide is to provide Ryan White HIV/AIDS Program providers and consumers with guidance on how to set up a Consumer Advisory Board (CAB).

CABs are the most common structures used to solicit feedback on Ryan White program services. CABs have changed over time serving various functions throughout the history of the implementation of the Ryan White HIV/AIDS Program legislation. Several tools have been developed to support the establishment of sustainable and effective CABs. There is an incredible opportunity to tap into the networks of existing CABs (as well as start new CABs) and to use these structures for quality specific feedback. Recruiting representative samples of patients and building community capacity for quality are key to CABs functioning in the healthcare system of today – which is more and more calling on patients to help in the design, redesign, and evaluation of services for improvement.

Contents

SAMPLE QUALITY CAB AGENDA

DESCRIPTION OF QUALITY CAB MEETING

SAMPLE CAB ACTIVITY – the HIV care continuum

Satisfaction Surveys

SAMPLE QUALITY CAB AGENDA

Agenda

CAB Information and Heading

Date and Location of Meeting

Agenda Item / Who / Time
Welcome and Introductions / CAB Chair / 5 min
Review – Previous Meeting / CAB Chair / 5 min
Introduction of Selected Measure / CAB Chair/Clinic QM Staff / 10 min
Review of Clinic Performance / Clinic QM Staff / 15 min
Review of Clinic Interventions and Hunches / Clinic QM Staff / 10 min
Feedback to Report and Clinic Response / All / 60 min
Next Steps / CAB Chair / 10 min
Adjourn / CAB Chair / 5 min

Expected Attendees: Members of the Consumer Advisory Board, Representative of the Clinical Quality Management Team/Committee, and Appropriate Clinic Staff for the topic (as well as any other associated staff)

DESCRIPTION OF QUALITY CAB MEETING

Pre-Meeting

Before each meeting the CAB Chair should meet with the Clinic QM Staff and review the upcoming meeting agenda including any performance reports and presentations. The CAB Chair should review the materials and determine:

  • Are the data presented in a way that will be understood by the CAB?
  • Are the key points summarizing the data meaningful?
  • Are the discussion questions appropriately designed to elicit feedback?
  • If the discussion goes out of scope – who will bring it back to the topic and how will this be done?
  1. Welcome and Introductions

In this section the Consumer Advisory Board (CAB) Chair (representative of the patient population) should call the meeting to order and remind members of the CAB purpose, role, and procedures. Allow for all present to introduce themselves and their purpose for attending the meeting – regardless of their perceived level of familiarity. The CAB Chair should be sure to welcome any clinical staff and ensure that all present are acquainted.

  1. Review – Previous Meeting

In this section the CAB Chair should review the minutes from the previous meeting (previously sent to members ahead of time to review) as well as provide any updates on previous unresolved action items or in process projects. This section is informative and should not fall into discussion – if a particular topic comes up, the CAB Chair should identify it as a priority for inclusion on a future agenda and table the issue until the Next Steps section where it can be addressed with full attention.

  1. Introduction of Selected Measure

Each meeting should revolve around feedback on performance, improvement projects, and experience. Presenting multiple measures at once might dilute your process or just confuse your audience. Pick the measure that is more important (with the increased focus on outcome measurement since the introduction of the viral suppression measure – this is both a topic of importance to the clinic as well as the community and might be a good place to start; another potential starting point would also be looking at retention) and then focus on it – and it alone.

In this section the CAB Chair should plan with the Clinic QM Staff who work with the CAB to introduce the selected measure by explaining:

  1. Why are we looking at this? Why is this important to me as a patient?
  2. What is the measure? Who are you measuring? If you aren’t measuring everyone, why not? Where can I find information on this measure (supply a copy of the written measure)?
  3. How can the CAB help in framing the problem and providing feedback that will be useful to this particular measure – define the role of the CAB in relation to the needed feedback so that as they review the data the feedback will be more focused.
  1. Review of Clinic Performance

In this section the QM Clinic Staff should review with the CAB the clinic’s performance on the selected measure. It is important that the CAB Chair review this presentation ahead of time to ensure that the presentation is consumer friendly and addresses audience literacy appropriately. This is a critical step in ensuring all your hard work makes sense! In the presentation be sure to include national benchmarks (remembering to continually reinforce new learning by explaining what benchmarks are and why we use them) and clinic goals. How did the clinic set those goals? Are there are other relevant ways to look at the data? Do we need to look at it by age? By race/ethnicity? By age and mode of transmission? Tell the story with the data and remember your audiences are less concerned with charts of numbers than the bottom line! Summarize key points in a conclusion slide.

  1. Review of Clinic Interventions/Hunches

In this section the CAB Chair (who ideally sits on the Clinical QM Team) and the Clinical QM Staff present what is currently being done to improve this score (identify the interventions – no matter how routine) and the hunches on what the QM Team thinks might improve these scores (hunches, proposed interventions, process change ideas). This is the “what we are doing” and “what we think we probably should be doing.” This is not the time for feedback! Present the information and then move into the discussion. Establishing and sustaining agenda item focus is important – keep discussion where discussion belongs – it has one whole hour dedicated to it for a reason, let the group get there with good Facilitation!

  1. Feedback to Report and Clinic Response

In this section the CAB Chair should lead a discussion with the group to provide feedback on the clinic performance, hunches and interventions, and other ideas. This discussion can be tailored based on the measure selected or the dynamics of a group. Often CABs have been patterned through the experience of members on other planning bodies which use Robert’s Rules – ensuring that a discussion doesn’t fall into motions and seconds is key to brainstorming. No idea is bad – we all work through multiple ideas and if a decision is needed we come to consensus about the conclusion – because these are subjective questions for the most part anyways! Votes drive wedges and turn discussions into soap boxes. Some ideas for sample discussion questions are:

  1. What were you initial reactions to our clinic performance?
  2. Use this as an opportunity to ensure the CAB understood the data
  3. Are there any interventions in addition to what we are already doing that might help?
  4. What are your reactions to our “hunches” on how we might seize on this information and opportunity?

It is important to allocate a lot of time for discussion – narratives contain the answers but sometimes you have to hear the story to get your wisdom. Allowing for each member to share their experience, while still facilitating and ensuring broad and equitable participation can be tricky, but it is important.

  1. Next Steps

In this section the CAB Chair should review the feedback provided during the CAB meeting and address any outstanding topics on the table for potential future meeting agendas. If more input is needed or feedback is desired on a product or process that will be completed before the next meeting, be sure to set up a way to get feedback via email, a conference call, or an ad hoc committee that could meet separately for this task.

  1. Adjourn

Remind participants of the next meeting (or any ad hoc meetings set during the meeting) thank everyone for their participation and close the meeting.

Post-Meeting

At the close of every meeting the CAB Chair should debrief with the clinic staff present. Asking questions such as:

  • What did you think went well?
  • Did the group understand the story you were trying to tell with the data?
  • Was the feedback useful? If not, how could we have crafted the discussion better?

SAMPLE CAB ACTIVITY – the HIV care continuum

Estimated Time: 90 mins (not including prep work)

Materials: Presentation Slides, Care Continuum, List of Interventions, Performance Data

Instructions

Pre-Activities:

  1. Review your performance and determine which “bar” of the continuum you would like feedback on (e.g. which bar is relevant to your current QI priorities and/or projects)
  2. After determining which “bar” of the continuum you would like to focus on determine the following:
  3. What interventions have we tried to address this but are no longer implementing?
  4. What interventions are we currently implementing to address this “bar” on the continuum?
  5. Who are we partnering with (if any) to address this area?
  6. What are our current hunches about how to improve this “bar” on the continuum?
  7. Using your performance data and the answers to the your questions, develop a presentation (template attached here) that presents:
  8. Overview of Care Continuum concept
  9. Personal Care Continuum
  10. Overview of relevant measures for selected “bar” of continuum
  11. Performance data on selected “bar” of continuum
  12. List of Past Interventions
  13. List of Current Interventions
  14. List of Partners
  15. List of Hunches
  16. Secure time on the agenda for the upcoming CAB meeting

Activity:

  1. Introduce yourself and explain your role in the clinic to CAB members. Explain the purpose of your presentation is to gather community expertise to help inform and improve projects aimed at making their care better.
  2. Using your presentation walk the CAB through an explanation of what a Care Continuum is, how to understand the graphic, and which “bar” of the continuum you will be focusing on for the activity.
  3. Review the CAB members the measures used in the selected “bar” of the continuum. Be sure to include the following:
  4. Indicator
  5. Indicator Definition
  6. Numerator
  7. Denominator
  8. Eligible Patients
  9. Exclusions

Review and answer any questions to clarify the measure and its importance in care delivery.

  1. Next, review with CAB members past and current interventions aimed at improving this measure. If you have tried something in the past and it didn’t work, explain that! This helps focus your CAB on providing new ideas rather than rehashing what were good ideas that just didn’t lead to improvement in your clinic. Once you have reviewed the clinic’s past and current efforts outline who are the clinic partners in the process (if pharmacists or the government are at the table supporting the project, be sure to let the CAB know, seeing the bigger picture is always valuable).
  2. Lastly review with the CAB the current “hunches” on what the QM Team thinks is going on and might improve this area of care.
  3. Next ask for participant feedback by asking the following questions:
  4. What is your initial reaction to the data?
  5. What are your reactions to our hunches about how to improve this area of care?
  6. Is there anything about this are of care we don’t know and we should?
  7. What are we not doing that we should be doing?

The questions can be tailored to your specific needs – if you want to drill down on a topic deeper and your CAB has the capacity then tailor the questions for more depth. The questions here are only suggestions!

Record the participant responses on flip chart to ensure that all participants see their experience and input being recorded and validated.

  1. After finishing your discussion questions review the key findings from the discussion to ensure that the CAB agrees with your initial reactions.
  2. Thank the CAB for their participation and record flip charts onto electronic documents

Post-Activity

  1. Use CAB feedback to inform and frame QI projects
  2. Close the loop – be sure to report back to the CAB both digital copies of their responses as well as how the QM Team used the information in the development, selection, or implementation of a QI Project or effort.

SATISFACTION SURVEYS

Satisfaction Surveys are probably the most useful tool used least effectively for quality purposes. Satisfaction Surveys help identify potential opportunities to improve the quality of care in consideration of the patient experience.

What tool to use?

Often organizations or clinics will spend a lot of time developing a survey tool to ask the questions that are just right for their clinic. While this process has value – one of our quality improvement principles is donot reinvent the wheel! There are MANY pre-tested and validated patient satisfaction tools – the National Quality Center has a Patient Satisfaction Survey posted on their website which has separate modules for Ambulatory Care, Women’s Health, Mental Health, and Case Management. You could use the whole tool or just small parts if you are trying to look at a certain aspect of your program. In utilizing pre-made and pre-validated tools, you will save valuable clinician and patient time.

How frequently do we administer the tool?

Many grantees administer a satisfaction survey on some annual basis. If the satisfaction survey is meant to help identify priorities for quality improvement and is the only method for patient feedback, it is imperative the data collection align with the quality planning process. Quality projects take a great deal of time from the initial root cause analysis into data collection into project planning into testing and finally evaluation and implementation. It often times takes at least a year to complete these tasks and sometimes even longer meaning an annual survey might be producing information at the wrong time in the improvement process. In addition, it is important that review of patient experience information is considering when selecting QI projects! Many times we have really good data before us but we miss the opportunity because the planning ship has already sailed. So perhaps administer a survey every two years and look to a more qualitative method of assessing patient satisfaction in the off year. There are several great examples of easy qualitative patient satisfaction tools and projects out there.

How to get the tool out?

This is a perfect opportunity to engage your CAB. Ask your CAB to think about all the places they engage their HIV care system. Make a list of the different locations and how you could potentially disseminate the survey tool. Some examples:

  • Survey tool sent via mail
  • Survey tool made available online
  • Survey tool handed to each patient by physician at the close of a visit
  • Specific tools handed out at end of specialty visits (Case Management, Mental Health, etc)
  • Survey tools handed out with ADAP prescription refills in your area
  • Survey tools made available at local ASO(s)

Brainstorming with your CAB will help you identify where to put your effort for the most impact.

What to do with the data?

Once you have collected the completed surveys and created your data report take the time to review the data with your internal quality management team (which hopefully has a patient representative) and get the reactions from your team. Ask key questions such as:

  • What do you see in the data, what are they telling you?
  • What are you seeing that you are really proud of?
  • Where are you seeing potential opportunities?
  • What areas might you be interested in focusing on?

Determine a few key points that you will later use to share with the CAB which is where you should go next to get reactions and responses to the data.

Because a CAB is a community board not all members may be comfortable with or have a good grasp of data – this doesnot mean they will have trouble understanding data, it just means you should tailor your data presentation to your audience:

  • Draw out from the data the highs and the lows.
  • Where did the clinic perform well and where did the clinic identify opportunities?
  • Ask the CAB for their reactions – do they see other areas that are important?
  • Present the areas that the quality management team was interested in and ask for reactions from the CAB.
  • Would they agree with these priorities? If so, how would they rank them? What would be their preferred quality improvement project?
  • Communicate that they are one of several voices in this process and you are taking their feedback to the quality team who will ultimately make the decision with their input.
  • Ideally there is a patient member on the quality team which helps build trust and transparency to the process.

Bring the CAB feedback back to the quality management team and determine your project. Report back to the CAB at the next meeting the chosen topic and begin to elicit ideas on how you could improve upon the chosen indicator. For example if the quality team chose to work on medical visit frequency, this CAB meeting should report the project selection and then solicit feedback on how the CAB thinks they could improve upon the indicator.