Flipping the Script: Using an Implementation Science Methodology to frame Quality Improvement across a multi-site, multi-provider HIV Care and Treatment Program

Abstract Information: The COVID19 pandemic placed an enormous amount of pressure on healthcare providers who were not necessarily accustomed to providing medical treatment in virtual environments and/or were required to report to an office, even if there were no patients. As a result of this pressure as well as other personal and social factors, the healthcare system is experiencing high levels of staff turnover yielding a less experienced, less knowledgeable workforce. Within federally funded HIV programs, quality management is a requirement to help mitigate some of these external factors. In healthcare, quality management uses data driven approaches to focus on the system of service delivery to a granular level in order to achieve or maintain a specific level of performance. Even where there has been staff retention, program managers are experiencing ‘quality fatigue’ following up to 20 years of practice. Indeed, many staff who engage in quality improvement projects will suggest that they are already doing everything that they possibly can to optimize clinical outcomes. On a bi-monthly basis, the Middlesex-Somerset-Hunterdon Transitional Grant Area reviews performance data, focusing on clinical indicators such as HIV viral load suppression and HIV Care visit frequency. Since 2019, in the study region, there has been a slight decline in viral load suppression (between 1-3%) and a 7% increase in the number of patients who are not medically monitored in alignment with Public Health Service Guidelines. It is unknown how many patients have dropped out of care completely. The ongoing mission of the Middlesex-Somerset-Hunterdon Ryan White program is to facilitate early diagnosis, early entry into care, reduce transmission through adequate treatment and reduce disparities; making retention in treatment a key indicator of program success. Recent attempts to define a region wide quality improvement project using traditional methods were not successful. As an attempt to provide focus, the Middlesex-Somerset-Hunterdon County Transitional Grant Area implemented a quality improvement project using an implementation science methodology to encourage programs to continue to engage in quality management when they are stressed and understaffed. Using this methodology has helped provider staff to understand how pertinent aspects of implementation lead to long-term improvements. An additional by-product of these procedures has simultaneously aided new program staff in both the documentation and implementation of procedures and workflows to address reduced performance, where none existed. The quality improvement project was titled 'Meaningful Engagement in Care and Treatment'. Six separate agencies participated in the selection of an evidence based intervention that fits the local context and had the required resources for implementation. Each agency prioritized key barriers to actualizing their locally defined goal and then developed strategies towards reaching their stated goals. Each program incorporated local implementation data monitoring to support their larger clinical outcome goals. Program staff participate in monthly meetings that include all providers as well as one on one meetings with their respective teams. Action plans are created every two months to identify next steps, target dates and responsible parties, promoting accountability. Implementation, System and Clinical Outcomes of the project will be described.

Relevance Statement: While quality improvement in healthcare has been in practice nearly 100 years it can be described as difficult to achieve (Marjoa & Bozic, 2012), The healthcare landscape is ever changing. Medical break throughs, public policy, proactive attempts to address disparities in access all impact how healthcare is viewed and the extent to which people are willing to become users of the system. With respect to HIV care, public health guidelines have changed over the last 30 years to incorporate new medications, adjusted indicators for starting medications, and shifts in national policy to ensure collaborative efforts between prevention programs and care and treatment programs. As such, while the provision of medical and social services has improved on a larger scale, other medical, as well as socio-economic barriers continue to be the dominating barrier towards access to care. While program staff have access to an entire system of resources, it can be difficult to define and actualize steps towards improvement. The Ryan White Treatment and Modernization Act requires that funding recipients allocate up to 5% of funding towards Quality Improvement activities; while ensuring the clinical quality improvement is not related to any activity that might be construed as administrative in nature. (Ryan White Treatment and Modernization Act, 2009). Traditional quality improvement methodology, initially developed and promoted by Walter Shewhard and later adjusted by Edward Deming (Moen & Norman, 2010 ) emphasize use of Plan-Do-Study-Act cycles as an iterative process that will eventually yield the desired outcome. A recent review of PDSA cycles and their outcomes in the literature has demonstrated that despite yielding publishable results, they not uniformly or rigorously implemented (Taylor et. al, 2014). This study shifts focus from the PDSA cycle without removing it entirely and encourages the development of procedures, documentation, training, and staff configurations that support improvement through implementation. Rather than deriving a project through problem analysis, an evidence informed project is selected and then personalized to the clinic environment based on the ability of the provide to successfully implement an improvement project within their agency. There is greater emphasis on process changes which helps guide and clarify additional steps, policy changes, and needed documentation of process. Marjoua, Y., & Bozic, K. (2012). Brief history of quality movement in US healthcare.Current Rev Musculoskeletal Medicine. Dec; 5(4): 265–273. Published online 2012 Sep 9. doi: 10.1007/s12178-012-9137-8 Moen, R. & Norman, C. 2010. Circling Back. Clearing up myths about the Deming cycle and seeing how it keeps evolving. Quality Progress. November.(pp. 22-28). Accessed 3/22/23. http://www.apiweb.org/circling-back.pdf Ryan White Treatment and Modernization Act (2009). Policy Clarification Notice 15.02, updated 9/1/2020. Accessed March 22, 2023. https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-15-02-cqm.pdf Taylor, M., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. & Reed, J. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality and Safety. Accessed 3/23/2023 https://qualitysafety.bmj.com/content/23/4/290