Quality Management Core Tool – Monitoring Instructions

1) Routine HIV screening follows CDC's Revised Recommendations for HIV Screening for Adults, Adolescents and Pregnant Women in Health Care Settings,
or
United States Preventive Services Task Force (USPSTF) Recommendations for HIV Screening

Include the following criteria specific to HIV screening in program policies/procedures. Attachment of the most recent DSHS-approved Work Plan is acceptable if you include all criteria below:

• Definition of the population eligible for routine HIV screening.
• Screening technology – conventional blood draw, rapid test or both.
• Routine HIV Screening Protocols, and Standing Delegation Orders (Health and Safety Code (HSC) §85.085), as applicable.
• Screening goals, including the number of tests to be performed and number of positive patients to be identified.

DSHS Monitoring staff will observe and document that:

• Contractor adheres to the routine HIV screening policies/procedures, and DSHS-approved Work Plan.

Before the review, DSHS Monitoring staff will request current or updated policies related to general and informed consent, and the forms/documentation used for the consent for, or declination of, HIV screening.

Monitoring staff will review:

• Consent policies and documentation used by staff to get consent, or refusal, for HIV screening and complies with Texas law. 

Before the review, DSHS Monitoring staff will request current/updated policies/procedures and ensure that:

• Policy identifies appropriate procedures and staff responsible for informing patients of their preliminary and confirmatory positive test results.

Monitoring staff will review and confirm with the Contractor:

• The process for delivering preliminary and confirmatory positive test results comply with Texas law.
• If 95% or more of patients with an HIV positive test result receive their results.

Before the review, DSHS Monitoring staff will request current/updated policies/procedures to ensure reporting of positive HIV test results to the appropriate local/regional health authority.

Monitoring staff will review the following processes with the contractor to ensure:

• Positive test results are documented and reported to the appropriate health authority within the stated timeframe under Texas law. For more information, refer to the DSHS HIV/STD disease reporting page.
• Contractor has identified staff and backup staff responsible for reporting positive HIV tests, including laboratory and provider reporting to the appropriate health authority.
• Contractor has developed a protocol that identifies staff responsible for initiating public health follow-up and documentation. 

• Data Security Policies and Procedures are reviewed in Section VI, 18) Data Security.

Training to be completed during the first year of employment include:

• HIV Navigation in Texas (HNT)
• Gender and Sexual Diversity Training
• Social Determinants of Health
• Trauma Informed Care (TIC)
• Health Equity Training

The contractor has documentation, including Certificates of Completions on file, of staff attendance at all DSHS-directed training, conferences, and meetings.

Before review, DSHS Monitoring staff will request a copy of the new staff orientation plan designed to ensure new staff are aware of the Routine Screening Program goals, policies, and clinical operations.

Before review, DSHS Monitoring staff will request documentation to determine the training is available to:

• Educate healthcare organization providers and staff about the routine screening program, HIV transmission and prevention.
• Ensure healthcare providers that participate in the routine screening project have access to training about the health disparities and biases related to persons living with HIV.
• Ensure healthcare organization clinical staff have access to receive at least one training and/or continuing education opportunity relevant to the routine HIV screening project.

The DSHS Monitoring staff will review with the contractor a sample of training offered to grant-funded routine HIV program staff. Training may include, but is not limited to:

• Annual training and educational updates related to HIV screening and services.
• Annual cultural competency training.
• Job skills training to staff in their respective roles to performing duties including:
  • Informing patients of routine HIV screening and obtaining consent;
  • Providing positive test results;
  • Providing referrals and confirming patients to HIV medical care, prevention counseling, partner services and other related services; and
  • Reporting positive HIV test results to the local/regional health authority.

DSHS Monitoring staff verifies that the staff development plan is based on an assessment of training needs, quality improvement indicators, and changing regulations or requirements.

Indicators for staff training needs assessments may include surveys, discussions at staff meetings, employee suggestions, and performance evaluations. Staff development is documented to include continuing education for grant-funded credentialed professional staff.

The contractor maintains monitoring and evaluation records of grant-supported program staff development.

Before the review, DSHS Monitoring staff will request the current/updated definition of the population eligible for routine HIV screening. The will also request the total number of HIV tests to be performed during the contract period.

The monitoring staff will review with contractor staff to determine:

• The percent of eligible patients that have had an HIV test to date.
• If the contractor is on track to meet their screening goal by the end of the contract term.

14) Grantee will ensure at least 75% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within one month and at least 90% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within three months.

Grantee will ensure that at least 75% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within one month and at least 90% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within three months.

In addition to HIV medical services, the grantee will ensure individuals are referred to other services, including housing, legal assistance and violence prevention as needed.  

Before the review, DSHS Monitoring staff will request current/updated protocols regarding confirming persons who test positive for HIV to medical care and other services.

The monitoring staff will review the following:

• Protocols to ensure patients who receive a positive HIV diagnosis are referred to HIV medical care and other services as appropriate.
• Contractor has documentation tracking referrals and medical appointments with an HIV clinician for a medical assessment and other related services.
• Signed formal agreements of collaboration and coordination with 1) local providers of HIV medical care and other services specific to the needs of the patient, and 2) local health department partner services, and data to care, if applicable. 

a) DSHS Monitoring staff will observe and review the following procedures to ensure services are delivered in a culturally responsive and sensitive manner, including low health literacy:

• Informing patients of routine HIV screening program with the option to decline, or opt-out
• Delivering positive test results

b) DSHS Monitoring staff will review relevant resources available to ensure services are provided in a culturally and linguistically appropriate manner, which may include but are not limited to:

• Employment of personnel that speak the language/s of persons served.
• Employment of the AT&T 24/7 Language Line Services or another platform.
• Contracting with appropriate interpreters including signers for the deaf or hearing impaired or using another platform.

Patient/client information/education materials are available in appropriate language/s.

The CQI Plan describes the process for conducting quality assurance activities including:

• A schedule to conduct CQI activities (conducted annually at a minimum).
• A procedure for activities, i.e., self-monitoring tool, CMS credentialing tool, DSHS QM tool, etc.
• Regular monitoring of program data and DSHS Performance Measures to evaluate and improve program planning, activities and services.
• Review of client satisfaction/grievance policy and procedures.
• Documentation of results, and corrective action plans are tracked and evaluated for improvement of services; results and follow-up activities are reflected in reports to the CQI Committee or in committee meeting minutes.

Refer to POPS chapter 16 – Routine HIV Screening in Healthcare Settings, 16.9 Quality Assurance section

The CQI plan describes the establishment of a multidisciplinary CQI Committee to include:

• Membership includes key leadership of the organization including the Executive Director/Chief Executive Officer and Medical Director, or designee as applicable, and key staff responsible for the routine screening program grant requirements.
• CQI Committee meets at least quarterly or more often as needed. 

• Contractor reports breaches of confidentiality/privacy incidents to DSHS TB/HIV/STD section Security officer, and fully assists DSHS in any breach-related investigations in compliance with DSHS Policies 2011.01, 2011.04, 2016.01. 

• Contractor complies with DSHS Policy 302.001 and 302.002 and maintains signed agreement. 

• All contractor staff assigned to work with HIV prevention program data maintain access to DSHS designated reporting system including e-authentication for access to EvaluationWeb for HIV testing data.

• All contractor staff assigned to work with HIV prevention program data complete required annual security trainings including:
  • DSHS Security and Confidentiality
  • HHS Information Security/Cybersecurity

• Data is submitted according to DSHS requirements.
• Timely communication notifying DSHS of delayed data submissions. Reasons for delayed data submissions are considered on a case-by-case basis. 

• Contractor ensures data is accurate and complete prior to uploading, including line level data and any DSHS-specific reports (monthly or quarterly), to EvaluationWeb, GlobalScape, or other reporting system designated by DSHS. 
• Contractor communicates with DSHS regarding improving data quality (accuracy and completeness), and any IT or computer issues.

Activities should include but are not limited to:

• Information technology has made or is working to incorporate changes that support data collection and reporting positive HIV test results to appropriate local/regional health authority per Texas law. It tracks project activities including electronic medical records, lab orders and test results, notification of positive HIV test results, and HIV-related medical/services referrals, confirmation to medical care, and quality assurance improvement activities.
• Contractor is working with community partners through networks and collaborations to ensure sustainability of routine HIV screening.
• Contractor cooperates with any DSHS-funded activities to raise awareness of HIV and promote prevention services.
• Contractor participates in local HIV planning and evaluation activities, as well as in local efforts to coordinate HIV prevention and treatment services.
• Contractor participates in the Texas HIV Syndicate, HIV Planning Councils, Fast Track City, or other collaborations to raise awareness of HIV in their communities, and to increase awareness of routine HIV screening in their facilities and other HIV prevention activities in their communities.