Quality of Care Programs
- NYS Quality of Care Program
- HIV Clinical Guidelines Program
- Part A HIV Quality Management Program
- National Quality Center (NQC)
- HIVQUAL-International (HQ-I)
- AIDS Intervention Management System (AIMS)
The AIDS Institute is committed to promoting, monitoring, and supporting the quality of HIV clinical services for people with HIV in New York State. The Office of the Medical Director coordinates quality improvement activities including the development of clinical performance measures derived from practice guidelines, on-site quality of care reviews, as well as the promotion of quality improvement activities, peer learning opportunities for HIV providers, and consultations to support on-site quality improvement efforts. The ultimate objective for each HIV program in New York State remains the development of a sustainable independent quality management program that reflects the capacity to dynamically analyze and continuously improve HIV treatment, care, and supportive services.
The Office of the Medical Director coordinates the participation of several groups of stakeholders to accomplish these tasks including: (1) an internal Quality of Care Workgroup based at the AIDS Institute, responsible for implementation and refinement of the program within the New York State Department of Health AIDS Institute; (2) the AIDS Institute's Medical Care Criteria Committee chaired by Dr. Judith Aberg, responsible for clinical guidelines development; (3) the HIV Quality of Care Clinical Advisory Committee chaired by Dr. Peter Gordon, comprised of expert HIV providers who advise on the development, implementation, and refinement of the Quality of Care Program; (4) the New York City Part A Quality Management Program Advisory Committee; and (5) the AIDS Institute's Consumer HIV Quality Committees. The AIDS Institute solicits feedback through these committees in planning, implementing, and evaluating quality of care program activities. The interaction of providers and consumers with the AIDS Institute through these various groups allows New York State to remain responsive to the needs of the communities that it serves, while responding to changes in clinical and scientific knowledge.
Statewide quality of care program standards that apply to all HIV health care facilities, regardless of their caseload, location or service delivery model have been developed, reviewed annually, and revised as needed. These standards ensure that the best clinical care is provided to patients throughout New York State by improving systems of care delivery and by stimulating quality monitoring. In addition to medical chart reviews, organizational assessment tools have been created to determine the extent to which these program standards have been implemented. Annual assessments of providers’ quality management programs are conducted by AIDS Institute staff and consultants. Data from these assessments are used to guide technical assistance and consultation to further enhance providers’ quality management programs and to develop future strategies to advance the statewide Quality of Care Program. Statewide and regional organizational assessment reports are developed and reviewed annually to assess areas of common need. Workshops, webinars and other opportunities for capacity building and peer learning are developed based on these findings.
All HIV programs throughout New York State are expected to self-report their quality of care performance data. In 2011, 186 HIV clinics submitted their performance data based on a review of 9,943 medical records. The HIVQUAL review was completed online using the eHIVQUAL application. HIV programs are able to submit their completed reviews online and to instantly access performance data results, allowing them to immediately utilize their data findings to prioritize upcoming quality activities. Data findings were presented to various provider stakeholders and consumer representatives. In 2010, for the first time, a statewide HIVQUAL quality review of programs providing adolescent HIV primary care was performed. Approximately 650 medical records were reviewed. Performance data results immediately accessible through the eHIVQUAL application allowed providers to use data results to prioritize improvement activities.
Facility-based results of the quality of care reviews are presented as aggregate data. Results for specific regions in New York State are provided as well, in a format that permits comparative evaluation and reference to performance standards while maintaining patient confidentiality. The results are used to target providers for assistance and consultation, rather than to penalize. In addition, Quality Improvement Profiles are developed for HIV programs that both receive an organizational assessment and submit their performance data. These profiles offer a succinct overview of longitudinal data results, organizational assessment results, and capacity building activities, and suggest opportunities for improvement.
AIDS Institute quality improvement experts provide professional assistance to further strengthen quality management programs in HIV facilities throughout New York State. They work with clinicians and administrative staff to set priorities for improvement initiatives and develop plans for quality improvement and ongoing internal quality monitoring. AIDS Institute staff and QI coaches provide education focusing on quality improvement methods, assist with the interpretation of data, and promote creative thinking by facility personnel to improve performance.
The Quality of Care Program has established several HIV Quality of Care HIVQUAL regional groups and clinical Learning Networks. These involve quarterly meetings that emphasizes peer interactions and learning. Structured meetings focus on quality management using existing performance measurement strategies, as well as group improvement projects. In addition to the face to face meetings, participants take part in webinars and regularly submit data reports on ongoing improvement activities. The goals of these groups are to improve the quality of HIV services, strengthen provider infrastructure, and increase competency in performance measurement. Ambulatory care groups currently engaged in these collaborative activities include NYCHHC hospitals, drug treatment centers with HIV primary care, community health centers, several upstate hospitals and community health centers, and adolescent providers. These groups and learning networks also provide a forum for work on group improvement projects.
The HIV Quality of Care Program continues to engage people living with HIV/AIDS (PLWHA). The HIV Quality of Care Consumer Advisory Committee has been focusing its attention on the following areas: involvement of consumers in quality activities, and concerns of the deaf and hard of hearing community. In 2007, a Youth Committee was formed to solicit feedback from HIV-infected adolescents and to routinely present concerns of the Youth Committee to AIDS Institute committees. Consumer Advisory Committee members continue to review upcoming adult, adolescent and pediatric clinical guidelines developed by the HIV Clinical Guidelines Program.
Recent areas of emphasis for these programs have included improving viral load suppression rates, patient retention, and maximizing use of clinical information systems to produce performance data. Annual New York State Quality Awards honor those quality champions that have excelled in areas of quality such as performance measurement, quality improvement and consumer involvement.
Daniel Belanger, LMSW
Director, NYS Quality of Care Program
Office of the Medical Director
Clemens Steinböck, MBA
Director, Quality Improvement Initiatives
Office of the Medical Director
The AIDS Institute's Office of the Medical Director directly oversees the development, dissemination and implementation of state-of-the-art clinical practice guidelines. These guidelines address the medical management and treatment needs of patients with HIV infection as well as the particular requirements of patients with mental health needs and substance use behaviors. This program also produces guidelines on specific issues that affect the health care needs of women with HIV infection and oral health care for people living with AIDS/HIV, and has recently begun working on guidelines for hepatitis C mono-infection and STIs in men who have sex with men.
AIDS Institute clinical guidelines are developed by committees of expert clinicians with experience in providing care to people with HIV infection in New York State. Each guidelines committee is charged with developing standards of care for patients within its area of focus, regularly identifying guidelines topics, assessing current recommendations, and reviewing and updating existing guidelines as necessary to keep information current with any emerging clinical and research developments. All new and revised guidelines undergo peer review and are also reviewed by consumers.
Current guidelines committees include:
- Medical Care Criteria Committee (Adult and Women’s)
- Committee for the Care of Adolescents and Children with HIV Infection
- Dental Standards of Care Committee
- Mental Health Guidelines Committee
- Committee for the Medical Care of Substance Users with HIV Infection
- Pharmacy Advisory Committee
- Steering Committee
The HIV Clinical Guidelines Program works in a coordinated manner with other programs in the AIDS Institute to promote implementation of HIV guidelines in New York State. Clinicians are targeted through the Clinical Education Initiative (CEI) and the AIDS Education and Training Centers (AETC). Supportive service providers are reached through the HIV Education and Training initiative. In developing quality indicators based on the guidelines, the Quality of Care program has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific aspects of the guidelines have been implemented in NYS.New and updated HIV clinical guidelines are posted directly on the program’s website: www.hivguidelines.org. Over 100 current guidelines are posted on the website--available to users throughout New York State and worldwide. All current guidelines, and related materials are available to be accessed online or downloaded. The guidelines program tracks and analyzes website usage to ensure the program continues to meet the needs of its users.
Tracy Hatton, MPH
HIV Clinical Guidelines Program
Office of the Medical Director
The Ryan White Part A HIV Quality Management Program, a partnership with the New York City DOHMH, focuses on building quality management capacity in programs receiving Part A funding in the New York Eligible Metropolitan Area (EMA), which includes New York City and Tri-county (Westchester, Rockland and Putnam counties). Mutual program goals are to improve the quality of supportive services, strengthen provider infrastructure, and to facilitate improvement activities at every stage along the HIV care continuum.
In recent years, the Part A QM Program has focused on developing selected indicators for specific services – for example, care coordination – that emphasize a focus on desired patient and service outcomes. The process emphasized not only consensus but ensured that quality measures reflected program priorities. Performance indicator data is drawn on an annual basis from existing program data, and indicator reports provide both an assessment of the effectiveness of program services and identify improvement priorities. The Part A QM program works with individual programs to develop and conduct QI projects intended to improve performance on these service indicators.
This program aligns the goals of quality management, service program objectives, evaluation, and patient outcomes in a meaningful way. It is intended to increase the involvement of all program staff and consequently broaden input and efforts toward improvement.The Part A QM Program continues to promote targeted coaching and support to assist providers as needed in identifying quality infrastructure needs, and provides guidance as needed in developing QI projects and in selecting and testing changes, with the overarching goal to support and sustain quality efforts in Part A programs by building service provider capacity. The program uses QI consultants as coaches who demonstrate their expertise by working with programs to apply QI tools and methodologies. These activities will lead to a more fluid sharing of expertise between service categories and strengthen the program. The QM program has begun to work with Part A programs to develop organization-wide quality management plans and organizational assessments, leading to more integrated quality efforts.
Tracy Hatton, MPH
HIV Clinical Guidelines Program
Office of the Medical Director
The New York State Department of Health AIDS Institute is funded by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau to develop and implement the National Quality Center (NQC) to serve as the primary national resource for quality improvement in HIV care. Since its inception in 2004, the NQC has provided national leadership and support in quality improvement for Ryan White Program-funded grantees nationwide and has become the premier technical assistance provider for federally funded HIV providers by meeting the demonstrated needs of Ryan White grantees for technical assistance in quality improvement principles and practice. The aim of this national initiative is to build capacity to improve the quality of HIV/AIDS care and services across the United States. The NQC delivers technical assistance through several modalities, including on-site coaching, peer learning opportunities, face-to-face trainings and dissemination of quality improvement resources.
On-site technical assistance is delivered to grantees through a nationwide network of expert quality improvement coaches. Grantees request technical assistance from NQC on a number of quality improvement issues including conducting an organization assessment of the quality management program, assisting in the development of a written quality management plan, providing staff training, developing and implementing performance measures and benchmarks, and reviewing data collection methodologies. The NQC serves close to 250 grantees nationwide across all Ryan White funding streams. Based on recent evaluations, results have shown that the provision of ongoing consultations by expert coaches to Ryan White grantees results in advancements of the quality management infrastructures and significant improvements in many key quality improvement areas that all grantees meet their legislative quality management expectations.
To foster local communities of learners, the NQC launched several cross-state collaboratives, which were modeled on the Institute for Healthcare Improvement’s (IHI) Breakthrough Series. The aims for these initiatives focused on alignment of quality management goals to cooperatively meet the federal legislative mandates, and to advance the quality of care for people living with HIV within the respective constituencies. The Cross-Part Collaboratives involved five states (Connecticut, Texas, Virginia, Pennsylvania, and New Jersey) and all of the 86 Ryan White grantees, representing 19% of people living with AIDS in the U.S. Over the course of the Collaborative, collaboration and alignment across grantees improved and all performance measures increased.
In 2011, NQC launched its first-ever national campaign, called in+care Campaign, engaging grantees across the U.S. in an effort to reengage those individuals who have been lost to care. This national retention initiative is in keeping with the goals of the National AIDS Strategy, and recognized as an issue in HIV care that needs a nationwide focus. The campaign has its own website, complete marketing materials, and a central data repository for grantees to enter their data and obtain benchmark reports. Over 650 HIV programs across 45 states in the U.S. have signed up to participate in this national effort, serving over 470,000 HIV patients (not unduplicated). Approximately 51% of all Ryan White grantees are enrolled in the in+care Campaign, representing the largest quality improvement initiative in Ryan White history.
NQC has developed multiple face-to-face training opportunities for grantees. The NQC Training-of-Trainers (TOT) Program directly assists Ryan White Program grantees with building training capacity in quality improvement practice. The TOT Program aims to increase the number of national quality improvement trainers and provides networking opportunities for participants with other HIV providers from across the country. The Training of Quality Leaders (TQL) Program provides participating grantees the ability to enhance their own expertise in quality management, the skills needed to work as facilitators to guide the development of sound quality management programs and/or quality improvement projects with impact on patient health outcomes, and group facilitation skills to better address team dynamics. The newest training program, the Training on Coaching Basics (TCB) Program aims to close any educational gaps of quality managers and to increase quality improvement competencies by building the quality improvement capacity of quality leaders to coach other HIV providers on quality improvement. These advanced training programs reached 56% of all Ryan White grantees.
NQC disseminates quality improvement resources through a variety of vehicles. The NQC website at NationalQualityCenter.org, which currently hosts over 300 materials, posts comprehensive and up-to-date HIV quality improvement resources for HIV providers and consumers. The NQC Quality Academy is an on-line resource on various topics in quality improvement by offering over 35 tutorials in English and Spanish. These tutorials are available 24/7 and at no-cost. This resource has been used by grantees for staff training and is a rich source of materials specific to quality improvement in HIV care. NQC exhibits nationally at conferences with strong participation of HIV providers to distribute quality improvement materials. National technical assistance calls are offered monthly on a wide range of topics related to quality improvement. These monthly webinars attract grantee staff from around the country and provide a didactic component as well as opportunities to learn the quality improvement practice of individual grantees.
Clemens Steinböck, MBA
Director, National Quality Center (NQC)
Office of the Medical Director
HEALTHQUAL International is a capacity building initiative that provides technical assistance, coaching, and mentoring directly to Ministries of Health to strengthen and improve national health systems with the goal of creating self-sufficient local quality management programs that are sustainable over time. Quality improvement activities involve clinic staff and consumers with support from Ministry of Health leadership. These structural features are designed to be lasting even with staff turnover, organizational leadership changes or political transitions. HEALTHQUAL International is funded through the federal government's President’s Emergency Plan for AIDS Relief (PEPFAR) in 14 countries in Africa, the Caribbean, South America, and Asia.
HIVQUAL International was launched in Thailand in 2003, modeled on the NYS HIV Quality of Care Program and HIVQUAL-US initiative, expanding globally to PEPFAR participating countries including Uganda, Mozambique, Namibia, Haiti, Nigeria, Guyana, Kenya, Swaziland, Botswana, Rwanda, Zambia, Zimbabwe, Vietnam, and Papua New Guinea. Based on the quality management model developed by the New York State Department of Health AIDS Institute in 1995, the HIVQUAL model has been successfully adapted by Ministries of Health and implemented by country teams throughout these regions. In 2010, HIVQUAL International transitioned to HEALTHQUAL, a programmatic development reflecting our expanded focus on a public health approach to quality management, including and extending beyond HIV care, to encompass other chronic and infectious diseases. HEALTHQUAL is characterized by a broader focus on population health to strengthen overall quality of care across national health systems.
HEALTHQUAL adapts three basic components of quality management – performance measurement, quality improvement, and the quality management program – into a national program directed by the Ministry of Health and led by teams who are mentored by HEALTHQUAL staff, augmented by peer learning models and patient involvement. This includes coaching, provision of training, technical assistance, paper-based tools and software to country programs for both monitoring and documentation of the quality of patient care. Staff and consumer involvement support government-led capacity for the scale-up of HIV treatment and care and advancement of overall population health. Regional and district quality management groups foster implantation within structures of local government, creating expectations for ongoing, sustainable programs and rapid spread through peer learning.
Richard E. Birchard, MS
Deputy Administrative Director - HEALTHQUAL International
Office of the Medical Director
The AIDS Intervention Management System (AIMS) was created in 1986 to collect, organize, and evaluate data associated with the care of HIV-infected patients. AIMS is responsible for utilization reviews for HIV-related inpatient stays and Medicaid-funded ambulatory care; quality of care reviews for HIV Special Needs Plans enrollees and others as requested by AI leadership or the Office of the Medical Director; and analysis and reporting of data gathered through all review activities and special studies.
The goals of the AIMS program, currently administered through a third party contract include:
- creation of a review process that ensures services are necessary, appropriate, and meet professionally-recognized standards of care;
- development and management of data systems that support review activities and permit program evaluation and policy development; and
- identification of service needs and development of mechanisms to address shortcomings or inefficiencies.
During FY 2012, AIMS conducted approximately 92,131 reviews, including 31,301 quality-of-care reviews, 31,880 utilization reviews, up to 3002 maternal-pediatric HIV prevention and care program reviews, 513 DOCCS reviews and 27,786 Special Needs Plans program reviews. All quality-of -care reviews were conducted at ambulatory care sites. Reviews were conducted at acute care providers other than Designated AIDS Centers in an effort to assure that all New Yorkers with HIV receive clinically appropriate services regardless of site. Currently the unit monitors SNP contract compliance and conducts quality of care reviews at ambulatory care sites in SNP provider network.
Director, AIMS/Managed Care
Office of Medicaid Policy & Programs