Institute for Healthcare Improvement: Institute for Healthcare Improvement

Bruce D. Agins, MD, MPH Medical Director New York State Department of Health AIDS Institute New York, New York, USA
Bruce D. Agins, MD, MPH, has served as Medical Director of the New York State Department of Health (NYSDOH) AIDS Institute for over a decade, where he oversees the New York State HIV Quality of Care Program, guidelines development, and educational programs. Dr. Agins also serves as the Principal Investigator for the AIDS Institute’s National Quality Center, which provides quality improvement technical assistance to Ryan White grantees of all Titles across the country.
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Bruce Agins shares his thoughts on improving HIV/AIDS care and what he’d like to see the website accomplish.

Q: How do you see the changing face of HIV care?

A: Over the past five years, HIV has evolved from a terminal illness to a chronic disease as Highly Active Antiretroviral Therapy (HAART) regimens have slowed progression of infection and increased quality of life. As people with HIV are living longer lives, providers face a number of new challenges, including:

Changing demographics with a continued rise of cases among minority populations
New infections fueled by methamphetamine use
Increasing age of people living with HIV
Engaging and retaining HIV positive people in care
Recognizing prevalence of co-morbidities especially with regard to mental health
Coordinating HIV services across fragmented payer and delivery systems
Simplifying complex treatment regimens to maximize adherence
Reducing disparities of HIV care between different subpopulations
Integrating ongoing prevention counseling into care, including educating providers about strategies to help patients change behaviors and reduce risk
Managing general medical and preventive health care for people in middle age
Differentiating treatment side effects from symptoms related to other common non-HIV medical problems

Finally, society has recognized that HIV is a global problem and that efforts to control the epidemic need to be addressed through strategies that link countries with resources to those with limited resources.

Q: In your opinion, what have been the important milestones for quality improvement in HIV care in recent years?

A: Though there is much work to do, significant progress has been made to address challenges and barriers to implementing guidelines for HIV care in the US.

The Health Resources and Services Administration (HRSA) Ryan White CARE Act has funded care and support throughout the US, creating a continuum of HIV care and services throughout the country.
HRSA's HIV/AIDS Bureau has championed quality through its programs, emphasizing the importance of quality improvement by integrating requirements for quality management plans into contracts and program standards, and through the inclusion of supportive services in quality management plans of Title I and II grantees.
A national network of AIDS Education and Training Centers (AETCs) provide well-accessed decision support to HIV providers across the country.
Research reports such as the Institute of Medicine's Crossing the Quality Chasm and Measuring What Matters have documented the need to improve HIV care systems as well as standards and measures for HIV care.
Technical assistance programs such as the National HIVQUAL Project and the recently funded, National Quality Center (NQC) aim to support Ryan White CARE funded programs that provide care for vulnerable populations. The National HIVQUAL Project has demonstrated, over three years, an increase in performance rates on all HIVQUAL indicators apart from viral loading.
HRSA/IHI Collaboratives, specific to CARE grantee Titles III/IV and Title I were formed to foster peer learning and support for quality improvement. A Title II Collaborative will soon be launched by HRSA/NQC.
More quality improvement tools and publications specific to HIV care are available, and websites have been created to share quality improvement models, indicators, tools, best practices and publications.

Q: What is the overall role of NQC in advancing the quality of HIV care in the US?

A: NQC provides expert technical assistance to Ryan White CARE grantees with the most need to eliminate barriers to care and reduce disparities in the quality of HIV care across the US.

Quality improvement technical assistance is provided though information dissemination, training and educational fora, and intensive, tailored on- and off-site consultation to meet the quality improvement needs of CARE grantees. NQC helps to build program capacity for quality management and provide tools and techniques for quality improvement focusing on performance measurement, the science of quality improvement. NQC also facilitates linkages across CARE Act Titles through the vehicle of quality management plans.

Q: How do you see this website as a means to promote change in HIV care?

A: I see this website as a potentially dependable resource for HIV providers to access the best available knowledge about HIV-specific quality improvement strategies in order to close the gap between what is known about quality HIV care and current practices.

This website provides opportunities for peer learning and sharing best practices, and enables providers to apply methods for organizational change to improve systems of HIV care.

Q: How can NQC effectively respond to the needs of HIV providers?

A: By making the latest quality improvement resources available to providers and by building awareness, confidence and capacity to constantly improve HIV care.

NQC uses a triage process to work with grantees and their HRSA Project Officers to develop realistic and suitable technical assistance objectives for quality improvement. NQC consultants have extensive experience in various aspects of HIV care and quality improvement and are appropriately matched with grantees.

Q: How can consumers play a role in promoting quality improvement?

A: Consumers can offer invaluable feedback on the quality of their care through avenues such as consumer advisory committees, participation in planning committees, and patient satisfaction surveys.

Often, the perspectives of consumers become "wake-up calls" for providers who realize that certain strategies are ineffective, and that consumer priorities are not being addressed. Unless consumers can voice their priorities and needs, desired health outcomes are not likely to be achieved.