Clinical Quality Management
The HIV/STI/Viral Hepatitis Clinical Quality Management (CQM) page is a repository of resources, training materials, and program information regarding quality management and
improvement activities across the state of Indiana. The purpose of this page is for the Division to share timely information that promotes engagement in the statewide CQM program.
IDOH CQM Plan 2022-2023
Components of a Clinical Quality Management Program
- Quality Infrastructure
- The Indiana Department of Health (IDOH) is a recipient of the Ryan White HIV/AIDS Program (RWHAP) (Part B grant) and CDC Prevention Funds. IDOH administers these grants through the Division of HIV/STI/Viral Hepatitis.
- Within the Division, the Clinical Quality Management and Community Impact Program will be responsible for fulfilling The Division CQM plan. The Division CQM plan will be developed by the Director of Clinical Quality Management and the Continuum of Care Quality Management. As a Part B recipient, IDOH is required to develop and oversee the statewide planning and QI processes.
Clinical Quality Management Committees
- CQM Committee members will be recruited from both internal and external stakeholders.
- The Internal CQM Committee has representation from each program within the Division. Their membership on the committee must be approved by their program directors.
- The External CQM Committee is a standing committee. Members of that committee are representative of the programming funded by the Division across the state of Indiana. Consumers on the External Committee are chosen to represent each region of the state (Northern, Central, and Southern). Membership will be reviewed annually. There are no term limits on membership.
- Staff who are responsible for Clinical Quality Management duties and resources, as well as any contractors that may be funded to assist with Clinical Quality Management work.
- Resources for building capacity in order to carry out Clinical Quality Management activities.
- Allowable Clinical Quality Management costs include training and capacity building to recipients and subrecipients on CQM; membership dues for CQM-related professional organizations; quality-related certification, recertification, and continuing education; and cost associated with implementing CQM activities
Clinical Quality Management Plan
- Describes all aspects of the CQM program, including infrastructure, priorities, performance measures, quality improvement activities, action plan with a timeline and responsible parties, and evaluation of the CQM program.
- For more information, please see the HIV/STI/Viral Clinical Quality management plan here (insert link to CQM plan)
Involvement of People Living with HIV
- In alignment with the CQM/CI program’s core values of collaboration and transparency, it is essential to gain input from consumers and PWLE. Involvement of PWLE is necessary to ensure that the needs of people living with HIV are addressed by CQM activities
- Consumers will be involved the CQM/CI program through the ZIP Coalitions, HIV/STI/Viral Hep Advisory Council, Consumers Needs Assessment, External CQM Committee, as well engaged through quality improvement projects
- Involvement of agencies and people serving people living with HIV is critical to the success of our CQM program. By working with funded agencies and PWLE, we can create quality improvements projects that have the highest positive impact on people living with HIV
- Performance Measures
- Involves collecting and reporting data to set a baseline for improving care of people living with HIV, health outcomes, and patient satisfaction. Measuring key data of specific programs helps highlight the successes, and areas of improvement, within a program.
- Performance measures should be used to identify and prioritize quality improvement projects (see below) and goals of the CQM program. All measures are prioritized on relevance, measurability, accuracy, and improvability.
- For Ryan White funded agencies, performance measures from the HIV/AIDS Bureau (HAB) should be utilized for funded categories. For Non-Ryan White funded agencies, performance measures are solely selected based on priorities and ability to improve care delivery.
- Below is an example of a performance measure and all relevant pieces:
- Quality Improvement
- Quality Improvement entails the development and implementation of activities that make changes to a program in response to the performance data results
- IDOH and subrecipients are required to implement quality improvement activities aimed at improving patient care, health outcomes, and patient satisfaction
- IDOH and subrecipients are expected to implement quality improvement activities using a defined approach or methodology. Examples of QI methodologies are Model for Improvement, A3 Method, Lean, and Six-Sigma
- At least one QI project should be active at all times. QI projects can also span multiple services categories (i.e. improving Viral Load Suppression among Food Bank and Non-Medical Case Management clients).
Clinical Quality Management Resources
- Division Clinical Quality Management Plan
The IDOH HSVHD uses a division-wide approach to QM. The HSVHD Clinical Quality Management Plan (CQM Plan) provides a statewide framework for QM activities in Indiana. The CQM Plan includes detailed information on the roles and responsibilities of all stakeholders in the overall statewide QM Program. In addition, the CQM Plan includes the breakdown of quality performance measures by division program and provides the background on IDOH’s overall approach to QI. Download the 2022-2023 IDOH Inclusive CQM Plan.
- Statewide QI Projects
Statewide QI Projects
IDOH has produced the Community Health Improvement Initiative (CHII) as its landmark statewide QI Project. Service populations of focus and related topics are generated as a set curriculum and set of associated activities for subrecipient organizations identified for participation based on their organizational service populations. You will find details on CHII capstone projects over time in the table below.
New Recorded Training
Quality Management / Quality Improvement - The Basics with QM/QI
- Framework for Quality Management
Indiana Department of Health (IDOH) uses the RWHAP framework for QM seen to the right as the basis for its overall Division-wide QM framework. The Infrastructure for the QM program is rooted in the Division Clinical Quality Management Plan and the Indiana HIV, STI, and Viral Hepatitis Quality Management Committee described below.
CQM Technical Assistance Webinars
CQM Infrastructure Overview
CQM Performance Measure Overview
Statewide QI Projects and Reporting
Data Drivers: From Collection to Analysis Webinar Series
Date Content Slides Video 07/20/2021Data Drivers: Part 1, Fundamentals of Data Collection and Analysis Link Link 08/24/2021 Data Drivers: Part 2, I Have Data, Now What? Link Link
Indiana HIV, STI, and Viral Hepatitis QM Committee
Indiana’s HIV, STI, and Viral Hepatitis QM Committee (QM Committee) is a subcommittee of the Indiana HIV/STI Advisory Council (Advisory Council). Membership on the QM Committee is drawn from providers and consumers that represent all funded programs of the Division. Committee members represent diversity in geography, gender, and race. As a subcommittee of the broader Advisory Council, the work of the QM Committee is overseen by the Advisory Council in which all division sub-recipients of funding are required to participate.
IDOH HSVHD Internal QM Committee
The IDOH Internal QM Committee is made up of representatives from all division programs and is led by CQM staff. The purpose of the internal committee is to align CQM activities and expectations with other division priorities. The goal is for the Division to communicate expectations in one voice and avoid over-burdening sub-recipient agencies with overlapping or contradicting expectations.
- IDOH HSVHD QM Resource Center
IDOH has compiled a set of resources for sub-recipients that are creating and maintaining their quality management programs. Each sub-recipient received a binder of clinical quality management resources. Those resources can be found electronically here:
CQM Program Guidance
Federal guidance on RWHAP CQM expectations
Evaluation tool for CQM program operational quality
Example that can be adapted by your organization
A checklist of all components that should be covered in a CQM plan
QI Project Tools
Tool to help identify sub-steps to care processes
Tool to help generate change ideas tied to root causes
Tool to assist in QI project planning by step
Template to identify and report QI project progress
Repository of free QI tools!
Repository of free RWHAP tools, including CQM and QI
Tool to assist in creating processes that lead to consist, quality outcomes
Tool to assist in planning, implementing, and evaluating QI projects
Tool to assist in managing QI projects
Tool to concisely collect and report QI activities to ISDH
Final report from the 2019 needs assessment for people living with HIV in Indiana
The Clinical Quality Management Plan that guide’s division quality management activities
Accompanies HSVHD CQM Plan
Quick tips for creating effective performance measures
Resource from the Center for Quality Improvement and Innovation with QI/QM educational activities
- Performance Measurement Methods
HSVHD has developed a performance measurement system to chart system progress in quality over time. In this system, IDOH staff relies on data submitted through regular programmatic reporting. IDOH analyzes data internally and then shares back aggregate system data on a regular basis.
- Contact Information
Have questions about QM or QI as it relates to the work of the division? Write us at: HIVQuality@isdh.in.gov.