Quality improvement (QI) generally describes the ongoing monitoring, evaluation, and improvement processes aimed at improving performance. It is a patient/client-driven philosophy and process that focuses on preventing problems and maximizing quality of care.

Evaluation comprises systemic studies conducted periodically or on an ad hoc basis to assess how well a program or system of care is working. Types of evaluation include process or implementation evaluation, outcome evaluation, impact evaluation and cost-benefit and cost-effectiveness evaluation.

At first, a quality management program can seem overwhelming, especially for small agencies with limited staff and administrative personnel. Steps towards quality improvement (QI) are intended to be guiding principles that, if fully implemented, will lead to a strong, sustainable quality management (QM) program. However, the most important step for you to take is to get started.

Begin with a self-assessment of your organization’s approach to quality and efforts that are in place. For example:

1. You may already have data available to inform quality activities (such as number of “missed appointments” or acuity levels of clients in case management), but you’ve never analyzed it in a formal manner.
2. You may have a team of case managers who are always finding ways to improve services (maybe this group can serve as your first QI project team).
3. You may be doing formal or informal client satisfaction assessment and have a history of responding to client suggestions for improvement.
4. You do regular chart reviews to make sure program requirements such as “Verification of HIV status” are in place.

Input from individuals who utilize your services is imperative for being able to provide the highest quality services possible. Consumers provide a unique perspective on all aspects of your program including facilities, system flow, and care components.  In order for this input to be useful, it must be consistently and systematically obtained.

While suggestion boxes and open requests for feedback can be helpful, more targeted and scheduled opportunities for feedback will provide a stronger foundation for meaningful input from consumers in the long run.

Scheduled surveys that ask the same questions over time are encouraged. These questions should be developed with input from consumers. This is where an active Consumer Advisory Board can be instrumental. Focus groups can also be used for this purpose.

The first step in choosing an indicator is to determine what you want to know about the quality of the services in your system. Starting with recognized standards of care or services is always a good first step. What is the performance standard that you want to measure? What did you say you were going to accomplish? How do you know that you were successful? Do you have data that supports key goals and objectives?

If you provide clinical care, an indicator you should measure is adherence to federal, state or local treatment guidelines to show that you are providing care that meets accepted standards. If you provide case management services, an indicator you should measure is adherence to established case management standards of care. For some services, such as case management, national standards are not established. 

HIV quality indicators from HIVGuidelines.org have also been developed as Measures on this website, including case management indicators. The HIV/AIDS Bureau’s CARE Act Technical Information and Education (CATIE) Library can also serve as a valuable resource for locating standards of care.

No. This depends on the variety of services provided by the organization and service system. Additionally, the size of the program, consortium area, state, or organization will determine the resources available to collect data and monitor numerous indicators. Try to include one key indicator for each goal and objective in your work plan. You can start small and increase the number of indicators over time. The most important point is to get started.

Many organizations have found it useful to allocate a position or positions (or portion of a staff person’s scope of work) to focus on quality efforts. Designating funding for quality activities assures that quality management (QM) activities will become a priority and that QI will become part of the day-to-day operations of your program.

Everybody at the individual provider or organizational level. At some point, everyone in your organization should be engaged in a QI project team. You want to avoid having the same people on the teams, except in small programs where staffing may be an issue. Larger programs should consider all staff persons when assigning team members.

For statewide or citywide initiatives, the quality management (QM) planning team should include all appropriate stakeholders who represent QM efforts at the agency and planning level. This should include: representatives from all providers, Planning Council representation, Consortium representation, QI experts in your system, administrative agency staff responsible for QM activities, Information Systems (IS) staff, and representation from local agency Consumer Advisory Boards or Persons Living With HIV/AIDS (PLWH/A) committees attached to the Planning Council or Consortium.

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Forming the Team

Some people are born team players and seem to understand innately how to work with a group of people to achieve a common goal. Some people aren’t. Individuals who are accustomed to being in charge and making unilateral decisions may have a difficult time adapting to a system that promotes a team approach to decisions. Organizations with an entrenched hierarchical structure may also find individuals slow to adjust to a philosophy of teamwork. However, it is important to remember that human beings are highly adaptable. Teamwork is a skill that can be taught and nurtured. Remain optimistic and give each team member ample time to adjust.

Sometimes team pressure alone will help to neutralize difficult personalities. When an individual continues to exhibit behavior that is counterproductive to the process, senior leadership may need to step in, and in some cases, the individual may be asked to leave the team. The important thing to remember is that no one individual should be allowed to hamper the momentum of the team.

Another element of dealing with difficult personality types is having good meeting processes in place that minimize the impact a difficult personality can have on your team. Effective meetings will have: (1) timed agendas distributed in advance of the meeting; (2) meeting ground rules agreed to by the participants; (3) clearly defined roles for key participants such as the chair, facilitator, recorder, etc.; (4) a clearly defined purpose for the meeting; and (5) meetings that start and end on time. Additionally, a work plan that clearly identifies the quality management (QM) process goals and assigns responsibilities and due dates helps to make teams more efficient. Huddles offer an alternative, streamlined meeting structure.

A variety of approaches can be employed to integrate quality improvement activities into your day-to-day operations. It is important to have a quality management (QM) plan in place with priorities supported by organizational leadership, by the providers in a service system, and by planning bodies. These priorities should be communicated to all program and provider staff. Quality improvement activity updates should be provided on a regular basis to program staff at the agency level and to planning bodies who will use QI results to assist in priority setting and resource allocation.

QI data collection, tracking systems, and improvement strategies can be folded into daily workflow. At the individual agency, each staff member should be included on some level to promote shared accountability and buy-in on all levels. Job descriptions should include quality improvement activities in every position. At the system level, all contracts should include specific language about expected QI activities, regular reporting, and targeted outcome goals.

Training of all stakeholders about QI tools and techniques is very important.  Understanding that the focus of QM is improving systems of care, not evaluating individual agency or personnel performance, will help alleviate the most common resistance to undertaking QI initiatives. Encourage dialogue and suggestions about improving care delivery from every level of the system of care to further enhance stakeholder commitment to a quality management program.

No. All services should be held to standards of quality and should be part of a comprehensive quality management (QM) plan. We know that supportive services can enhance an individual’s ability to adhere to his/her clinical care. If you provide both clinical care and supportive services, you will need to assess the quality of both. If you provide only clinical services and refer your patients to other organizations for case management services, you may want to assess the referral process and access issues to promote continuity of care. If you provide psychosocial support services, you will probably want to start by focusing on the services with the highest utilization in your agency. Administrative agencies will want to have good data for all the services funded and will want to make sure that the smaller agencies with fewer resources receive adequate technical assistance and support to participate in a system-wide QM plan.

The Health Resources and Services Administration HIV/AIDS Bureau (HAB) Quality Management Technical Assistance Manual outlines a nine-step approach to implementing a QM program. It is important for leadership to be visibly involved in the development of a QM plan that identifies priorities, sets timeframes, and identifies the staff/persons/committee responsible. A process to evaluate the QM plan should also be developed.

While a written plan should be developed, the lack of one should not hinder quality efforts. It is important to begin the quality improvement process and build the plan, systems and infrastructure from whatever stage you are at. Many programs have done some type of quality management, even if it has not been formally documented.

These activities often include:

• Client satisfaction surveys
• Data collection
• Site visits/chart reviews
• Some level of contract monitoring and reporting

In addition, the National Quality Center has put together a document to answer frequently asked questions on how to develop an effective quality management program from programs receiving Ryan White CARE Act funding.