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Clinical Quality Management

Components of a Clinical Quality Management Program

IDOH CQM Plan 2022-2023
  • 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.
    Dedicated Staffing
    • 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.
    Dedicated Resources
    • Resources for building capacity to carry out Clinical Quality Management activities.
    • Allowable Clinical Quality Management costs include training and capacity building to recipients and sub-recipients 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, an 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.
    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. The involvement of PWLE is necessary to ensure that the needs of people living with HIV are addressed by CQM activities.
    • Consumers will be involved in the CQM/CI program through the ZIP Coalitions, HIV/STI/Viral Hep Advisory Council, Consumers Needs Assessment, and External CQM Committee, as well as engaged through quality improvement projects.
    Stakeholder Involvement
    • 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 improvement 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 sub-recipients are required to implement quality improvement activities aimed at improving patient care, health outcomes, and patient satisfaction.
    • IDOH and sub-recipients 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 service 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.

  • 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 sub-recipient 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

    CHII Topic

    Active Dates


    Final Report

    African American MSM


    Executive summary

    Adolescents (<24 yrs)


    Executive summary

  • 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.

  • Webinars

    CQM Technical Assistance Webinars





    CQM Infrastructure Overview



    CQM Performance Measure Overview



    Statewide QI Projects and Reporting


    Data Drivers: From Collection to Analysis Webinar Series
    Data Drivers: Part 1, Fundamentals of Data Collection and Analysis
    08/24/2021 Data Drivers: Part 2, I Have Data, Now What? LinkLink
  • Committees
    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

    HRSA PCN 1502

    Federal guidance on RWHAP CQM expectations

    CQM OA for Subrecipients

    Evaluation tool for CQM program operational quality

    Subrecipient QM Plan Template

    Example that can be adapted by your organization

    CQM Plan Checklist

    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

    Driver Diagram

    Tool to help generate change ideas tied to root causes

    Project Planning Form

    Tool to assist in QI project planning by step

    PDSA Worksheet

    Template to identify and report QI project progress

    IHI QI Essentials Toolkit

    Repository of free QI tools!

    Tools for HRSA’s RWHAP

    Repository of free RWHAP tools, including CQM and QI

    IHI Developing Reliable Processes

    Tool to assist in creating processes that lead to consist, quality outcomes

    QI Project Planning Guide

    Tool to assist in planning, implementing, and evaluating QI projects

    IHI QI Project Management

    Tool to assist in managing QI projects

    QI Project Reporting Form

    Tool to concisely collect and report QI activities to ISDH

    Other Resources

    Report: What Matters to You?

    Final report from the 2019 needs assessment for people living with HIV in Indiana

    2020-2021 IDOH Integrated CQM Plan

    The Clinical Quality Management Plan that guide’s division quality management activities

    CQM Plan Glossary of Terms

    Accompanies HSVHD CQM Plan

    IHI Tips for Effective Measures

    Quick tips for creating effective performance measures

    CQII Game Guide

    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: