Chattanooga Cares is a privately owned, not-for-profit HIV/AIDS clinic located in downtown Chattanooga. Owned and operated by Dr. Jay Sizemore, it was founded in December 2003 to provide medical needs for the underserved HIV positive patients in Chattanooga, Tennessee and 22 surrounding counties. Although its staff is small, consisting of a full-time work force of less than 30, they serve their community by offering AIDS testing, counseling, HIV treatment plans, and assistance with employment, housing, transportation, and childcare. Chattanooga Cares has one very important goal – reducing the levels of sickness in HIV/ AIDS patients. Therefore, the management team has designed a Quality Improvement Plan to tackle this goal. This aspiration has two components; the first concerns itself with the education of the community, and the second revolves around reducing the levels of sickness in already affected patients.
Implementation begins with education of the staff in areas of HIV/AIDS protection, treatment, and counseling. Outreach programs, taught by the staff, will be offered to guide the community in AIDS awareness. Data collection tools such as patient tracking system and disease specific flow charts will be utilized to scrutinize the effectiveness of the program. The plan-do-study-act approach to collecting data, monitoring, evaluating, and adjusting will be used to ensure that constant changes can be made to reach our goals. Chattanooga Cares will use competitive benchmarking to determine if their levels of sickness are in line with other clinics in the area. Finally, each person will compile his set of data and report to the management team for evaluation of the plan. The team will use the information collected to make adjustments going forward. This collaboration will be completed on a monthly, quarterly, and annually basis.
Chattanooga Cares Quality Improvement Plan
Quality improvement cannot be implemented without setting the performance standards needed to determine how improvement can succeed. Chattanooga Cares, a non-profit HIV/AIDS clinic, bases its quality improvement plan around the consumers of their services. Chattanooga Cares is a privately-owned AIDS and sexually transmitted disease clinic in downtown Chattanooga, Tennessee. It consists of a small staff of medical personnel, counselors, administrative staff, and volunteers. The staff offers HIV/AIDS testing, medical treatment plans, counseling, life coaching, and economic assistance through various housing, childcare, and financial institutions. The clinic derives its funding from government grants and community fund-raising events.
Chattanooga Cares (2013) mission statement is, “Our focus is AIDS: education, prevention and support for all people affected by HIV” (About Us). Since the patient, and the patient’s network of friends and family, are the central elements in Chattanooga Cares’ mission statement, the role of the patient is integral in quality improvement plans. There are few goals that do not involve the client. Although the clinic is privately-owned, it proudly displays its goals to the public. Because of its grant status, the treatment center must supply statistical information to the governmental agencies that provide the grants. All this information is readily available to the clients that consume their services.
Goals and Objectives
Some of the quality improvement goals of Chattanooga Cares are reducing the number of new patients infected by AIDS each year; lowering the economic hardships on their clients; maximizing efficiency and cost effectiveness within the office; and increasing training and education of staff. The clients play a major role in what performance standards are chosen. A few of the quality indicators that consumers use in regard to Chattanooga Cares are health outcomes and length of survival rates, screening and treatment frequencies, and satisfaction evaluations. Using feedback from stakeholders effects the way in which future services are conducted and funding is attained. In order to begin a quality improvement plan, certain quality performance standards need to be determined to measure the levels of improvement. Performance standards concern themselves within a health care organization.
Palmer (1997) suggests that clinicians must set performance standards on their individual practices and offer feedback to health care authorities. Two examples of these standards are defining the rate of re-admittance after completing a procedure and setting a limit for number of patients seen daily. Once the standards are determined and goals are set, compilation of everything is developed into the quality improvement plan. The quality improvement plan is the all-encompassing strategy while the performance standards are the steps needed to achieve it.
Scope, Description, and Quality Improvement Activities
The first part of the improvement goal of Chattanooga Cares is one of reducing the current levels of HIV/AIDS in the 23 counties the organization serves (“Chattanooga Cares”, 2013). By reducing the number of people affected by the disease, the overall health status of the community will improve and the economic effect on the health care system will be positive. Since 65% of current patients (“Chattanooga Cares”, 2013) cannot currently obtain health insurance due to their health status, a decline in the infected population will mean less public monies are needed to support the health care of the indigent population infected by the AIDS disease.
The best outcome of reaching this goal is a suppression of the AIDS infected population. Education in the community improves the knowledge base of the community as they learn the risk factors of AIDS contraction and hopefully use that wisdom to make wiser choices in sexual partners and intravenous drug usage. Through careful management of current patients’ progress, the team at Chattanooga Cares can evaluate and adjust the health regimen and assure that proper techniques and medication are being used.
Data Collection Tools
The main goal of Chattanooga Cares revolves around reducing the level of sickness in patients. The data needed are tracking patient progress through the treatment process, and current information of HIV/AIDS manifestation and control. Following patient progress is achieved through the usage of a reminder tracking system. As soon as a new patient is entered into the electronic medical records of the clinic, a tracking system immediately forms to trace the medical journey of the client (Hashim, Prinsloo, & Mirza, 2013). The system sends out emails, automated phone messages, or texts to patients reminding them of doctor and counseling appointments. It prompts the case manager to contact the patient personally and ask them questions about their general health, response to medication, mental state, and other factors such as housing, employment, and childcare status. By entering information into the tracking system, adjustments can be made to assure that the patient does not degrade in physical and mental health status.
This tool can help prolong the lifespan of the patient and help them get better. Over long periods of time, as a patient has developed an effective health regimen, the system stills tracks their progress and reminds the case manager to touch base from time to time. The strengths of this system are that a patient does not drop out of the program and their health status is continually monitored and improved upon. The weakness is that the ongoing information must be entered into the system to be effective; if the staff is too busy or forgets to follow up, then the health of the patient may be compromised. The measurement and display of this tool could be shown through weekly reports which show the number of patients whose contact reminders have not been completed.
The last data tool used to track current information on HIV/AIDS is a disease specific flow sheet (Hashim, Prinsloo, & Mirza, 2013). This chart contains information on the steps needed to test and treat people affected by HIV/AIDS. It allows clinicians to follow a prescribed course of medication and counseling for patients and permits changes in the course of health management. The benefits of using this flow chart is that treatment is spelled out for virtually every type of AIDS related illnesses and gives doctors a reference to follow. The only detriment is that the clinic must make sure to have current flow sheets which show new drugs and regimens for patients. If the clinicians are using outdated materials, then best practices are not being put to use.
Quality Improvement Processes and Methodology
The plan-do-study-act (PDSA) approach to quality improvements is one of small cyclical changes between processes and outcomes. It focuses on making little changes instead of large, broad strokes that can sometimes be too large to tackle at one time. Hughes stated (2008) that the purpose of PDSA is one that tries to “establish a functional or causal relationship between changes in processes (specifically behaviors and capabilities) and outcomes” (p. 33 Chapter 44). The PDSA cycle begins by defining the disposition and extent of the issue, what modifications can and should be made, a strategy for a specific change, who should be participating, what should be gauged to comprehend the effect of change, and where the stratagem will be directed. Change is executed and data and materials are collected.
The results are studied and clarified by using key measurements that show the levels of success or failure. New steps are developed based on the results and the process begins again (Hughes, 2008). This approach to quality improvement is positive in that allows extensive problems to be disentangled at a rate not overwhelming to those involved. Because PDSA is readily achievable and results are easy to decipher, almost instant gratification can occur. This makes a monumental task easier to tackle – much like eating the proverbial elephant one bite at a time. The drawbacks to this approach are that it is reactive and relies on people to accept constant change in their facility that can result in change fatigue (Hughes, 2008).
To achieve the QI goal, the clinic must review continually the data retrieved from the tracking system of patients’ progress through the treatment process. Therefore, the methodology chosen for Chattanooga Cares’ QI plan is PDSA. Because this system focuses on small, continual changes, it will be helpful in staying on track. Another reason for this choice is that the clinic is small and is used to a frantic pace, therefore change is commonly accepted and a part of the norm.
Comparative Databases, Benchmarks, and Professional Practice Standards Hughes (2008) describes benchmarks in health care as “the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance” (p. 38, Chapter 44). Competitive benchmarking can be used to compare Chattanooga Cares’ levels of sickness to other organizations offering the same services (Kay, 2007). By using reports from other HIV/AIDS clinics, Chattanooga Cares can compare their levels of sickness to the patients serviced by other treatment centers.
Authority, Structure, and Organization
The authority structure of Chattanooga Cares is straightforward and simple. Because it is privately owned, there is no board of directors. Instead, Dr. Jay Sizemore, the physician who owns and runs the clinic is the head of the organization (“www.chattanoogacares.org/”, 2013). Five other positions comprised of a registered nurse, a medical assistant, an LPN, a patient health coordinator, and an office manager, finish out the authoritative staff at the clinic. Although the doctor leads the team, the other five mentioned have equal standing in decision-making and quality improvement implementation. QI issues are discussed within the confines of these six people and all decisions are handed down from them. Each holds their own position within the organization, however, out of necessity, all of them work interchangeably within other people’s job duties.
Because of the intimate nature of Chattanooga Cares, quality plans are shared among all the staff. If a particular strategy involves essentially one person’s performance, that person will hold most of the responsibility for implementing, measuring, and ultimately, evaluating the effective of the plan. For instance, one goal is to improve the levels of sickness in the HIV/AIDS patients the clinic serves (“www.chattanoogacares.org/”, 2013). A tool for implementing and measuring this is a patient tracking system that follows a patient’s progress through the system.
The person responsible for this quality improvement device would be the case manager for that patient. This person would monitor the tracking system, collect data through reports, assemble data for team review, evaluate the effectiveness of the QI plan, and ultimately, apply needed improvements. Each person is responsible for his part(s) in any given QI plan as well as gathering data and reporting such data to the team.
All medical staff must be board certified and all case managers must have a background in social work and be at a minimum a licensed LPN. All education and prevention staff must be state certified in HIV/AIDS testing and prevention counseling (“www.chattanoogacares.org/”, 2013). Annual training and certification is required by all employed and volunteer staff to meet conditions of state and federal grant programs. To implement the patient tracking system quality improvement plan, each person working with patients will be included in the introductory training of the software program and be introduced to the goals of the QI plan.
This will be communicated by the person overseeing the process, most likely the case manager. Because staffing at the clinic is minimal, this training can take place efficiently, with little loss of productive medical time with patients. The process will be covered from the initial contact with a patient and will continue as long as the patient wished to be under the clinic’s health care plan. Therefore, it is ultimately the responsibility of the entire staff and not just the case manager, to ensure that current information is uploaded to the tracking system, and that prompts by the system are met in a timely manner.
The evaluation of the QI plan for improving sickness levels in patients’ is done on monthly, quarterly, and annually bases. Because continual evaluation is needed for the plan to succeed, data must be collected before it becomes overwhelming in numbers. If this plan was left entirely to an annual evaluation, it would take weeks, if not months, to assemble, evaluate, and implement changes. The factors gauged are made of up several items – reports showing the follow-up times of patients, data indicating how many patients did not receive required contact during the time period, and the time frames of between the system prompts and response intervals.
When complied, this data shows the breakdown in interaction and allows the team to make changes to ensure that patients do not lack in communication between themselves and the clinic. Monitoring the data on a weekly, if not daily basis, allows the QI plan to be more effective by making changes using the PDSA approach.
Hashim, M. J., Prinsloo, A., & Mirza, D. M. (2013, Spring). Quality Improvement Tools for Chronic Disease Care – More Effective Processes are Less Likely to be Implemented in Developing Countries. International Journal
of Health Care Quality Assurance, 26(1), 14-19. DOI:10.1108/09526861311288604
Hughes, R. G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK2682/
Kay, J. F. (2007, February). Health Care Benchmarking. The Hong Kong Medical Diary, 12(2), 22-7. Retrieved from: http://www.fmshk.org/database/articles/06mbdrflkay.pdf Palmer, H. R. (1997, October). Using Clinical Performance Measures to Drive Quality Improvement. Total Quality Management, 8(5), 305-11. Retrieved from http://search.proquest.com.ezproxy.apollolibrary.com/docview/219816031 www.chattanoogacares.com (2013). Retrieved on September 3, 2013 from: http://www.chattanoogacares.org/about-us.html