Overview of Quality Assurance and Enhancement

1
Overview of Quality Assurance and Enhancement

• A Framework for Moving from Quality Assurance to
  Quality Management
• Ohio Association of County Boards of Mental
  Retardation and Developmental DisabilitiesJune
  Rowe Human Services Research Institutejrowe_at_hsri
  .org

2
Definitions

• Outcome Reflect the goals of the service and
  represents a measurement of the effect or impact
  of the service on the individual and family
• Example People in service are provided quality
  health care
• Indicators would tell you the if
• desired goal has been achieved or would
• contribute to achieving that result
• Example People have an annual physical exam
• People have a primary care
  physician

3

Some More Definitions

• QA Process or Measure Processes and methods of
  assessing, collecting and analyzing data related
  to the indicator
• Example Survey or record review of dates of
  medical exams, compared to total number of people
  in service population
• Data Source Where the data can be found
• Examples Consumers, families, advocates,
  professionals, written information such as case
  notes, monitoring reports

4
Even More Definitions

• Quality Assurance Structures and processes that
  ensure compliance with all applicable laws,
  regulations, policies, and contracts/agreements
  that set forth standards of performance
• Quality Improvement Structures and processes
  that promote best practice and continual
  improvement in the provision of services and
  supports.
• Quality Management The use of quality data from
  multiple sources to track performance, improve
  services, and remediate systemic problems.
• Reports Documentation of findings and
  recommendations for corrections and/or
  improvements based on data that are analyzed,
  interpreted and validated by qualified reviewers

5

• Current factors in services and supports
  contributing to changes in Quality Assurance and
  improvement efforts.

6
Changing Quality Landscape

• Exposure of fault-lines in the system (e.g., GAO
  report, etc.)
• Emergence of self-determination
• Olmstead decision and proposed closures
• Struggles with MIS applications
• Direct support staff shortages
• Expansion of supports to individuals on the
  waiting list

7
23 States have been sued for wait listing
individuals with developmental disabilities for
Medicaid long-term services
Gary Smith, HSRI, 2003
8

• Decreasing/static funding coming on top of an
  already strained provider network
• Increasing federal expectations regarding a
  quality framework and quality management
• Inefficient business model (e.g., clumsy rate
  structures, redundant, sometimes conflicting
  monitoring processes)

9
Signs of Change in Performance Management

• No longer just better than the institution
• Rooted in outcomes
• Emphasis on enhancement and CQI
• Changing role of the state
• Changes in experiences of families and people
  with developmental disabilities
• Changes in accreditation approaches

Inclusion
10
More Signs of Change

• Movement away from prescriptive standards to
  individualized
• safety/risk planning and prevention
• Collaborative development of standards
• Inclusion of consumer and family participation
  in oversight (e.g., PA MN)

Satisfaction
Consensus
CQI
11
What does this mean for quality assurance

• QA is much less focused on one size fits all
  standards
• More focused on person-centered outcomes

• Respect and dignity
• Rights and responsibilities
• Personal safety and risk
• Abuse neglect (critical incidents)
• Individuals funds
• Health and medication
• Community inclusion and integration
• Independence and autonomy
• Choice and decision-making

12

• CMS is also opening up the discussion about
  quality..
• The Quality Framework

13

HCBS Quality Framework
14
Participant Access

• Information and Referral
• Intake and Eligibility            
• User-friendly processes
• Eligibility determination
• Referral to community services
• Individualization of services
• Prompt initiation

15
Participant-Centered Service Planning and Delivery

• Participant-Centered Planning
• Adequate assessment
• Free choice of providers
• Responsive service plan
• Participant direction
• Service Delivery
• Ongoing service and support coordination
• Provision of needed services
• Ongoing monitoring
• Responsiveness to changing needs

16
Provider Capacity and Capabilities

• Availability of individual and agency providers
• Review of provider qualifications
• Monitoring of providerperformance

17
Participant Safeguards

• Prevention and investigation of abuse,
  neglect and exploitation
• Tracking of major and unusual incidents
• Ensuring safety of housing and environment
• Regulation of behavior interventions
• Standards for medication management
• Provisions for personal safety and security
• Preparation for natural disasters and other
• public emergencies

18
Participant rights and responsibilities

• Ensure that participants  
• Exercise civic and human rights
• Participate in decision making authority
• Have provisions for alternate decision making
• Have access to due processand grievance
  mechanisms

19
Participant Outcome and Satisfaction

• Participant outcomes
• Participant satisfaction

20
System Performance

• Conduct system performance appraisals
• Support quality improvement
• Ensure cultural competency
• Support participant stakeholder involvement
• Maintain financial integrity

21
(No Transcript)
22
(No Transcript)
23
Continuous Quality Improvement

• Close the loop
• Information from quality assurance
• drives decision making!
• 
  Therefore.

24
Continuous Quality Improvement
25
Developing a Quality Management Strategy
26
Design Features

• Developing Areas of Focus and
• Outcomes and Indicators
• All key stakeholders involved in development
• Reflects the values and mission of the agency
• Is the foundation for the information that is
  consistently collected throughout the
  organization
• Is the basis for service decisions and
  benchmarking change over time

27

• Outcomes and Indicators
• Key Features
• Indicate that the desired result has been
  achieved or where it is in the process
• Are measurable and are items that can be measured
  throughout the organization and over time
• Basic Types
• Person-centered
• Provider
• Systemic or organizational

28
Examples of outcomes and Indicators
Area of Focus Protection from Harm
Outcome Safeguards are in place to protect the person from critical incidents.
Person-Centered Indicators
People and family members report they understand the reporting system for critical incidents
Provider Indicators
Staff are knowledgeable about and implement the incident management policies and procedures.
System Indicators
Statewide critical incident trends are reviewed and strategies for prevention are developed and implemented. Reports of abuse, neglect, and other critical incidents are submitted and investigated in accordance with approved guidelines and are resolved in a timely manner.


29
(No Transcript)
30
Discovery

• QA Processes or Measures
• Key feature
• Must be able to collect the information reliably
  across the entire system!

31
Examples of QA Processes or Measures
Domain Protection from Harm Regulations, policies and procedures Current QAQI Processes
Person-Centered Indicators
People and family members report they understand the reporting system for critical incidents Statewide critical incident training sessions for individuals and families Human rights training requirements for direct support professionals (DSPs) Consumer and family survey Case manager monitoring
Provider Indicators
Provider staff are knowledgeable about and implement the incident management policies and procedures. Incident management training requirements for DSPs. DD certification process
Reports of abuse, neglect, and other critical incidents are submitted and investigated in accordance with approved guidelines and are resolved in a timely manner. DD critical incident reporting rules, policies and procedures Web-based incident reporting system Critical incident database
System Indicators
Statewide critical incident trends are reviewed and strategies for prevention are developed and implemented. Same as above Critical incident database
32
(No Transcript)
33
Remediation

• Key Features
• Access to real time information
• Be able to respond to and correct serious health
  and safety issues when they occur

34

Examples of Remediation
Domain Protection from Harm Regulations, policies and procedures Current QAQI Processes Remediation
Person-Centered Indicators
People and family members report they understand the reporting system for critical incidents Statewide critical incident training sessions for individuals and families Human rights training requirements for direct support professionals (DSPs) Consumer and family survey Case manager monitoring Follow-up by case managers
Provider Indicators
Provider staff are knowledgeable about and implement the incident management policies and procedures. Incident management training requirements for DSPs. DD certification process Provider Plan of Improvement Follow-up Immediate jeopardy
Reports of abuse, neglect, and other critical incidents are submitted and investigated in accordance with approved guidelines and are resolved in a timely manner. DD critical incident reporting rules, policies and procedures Web-based incident reporting system Critical incident database Real Time tracking of critical incidents
System Indicators
Statewide critical incident trends are reviewed and strategies for prevention are developed and implemented. Same as above Critical incident database
35
Quality Improvement or
Closing the Loop
Who needs the information and why??
36

• Information from quality assurance
• should be used to drive decision making!
• Therefore.
• Information should be readily available
• and easily accessible

37
(No Transcript)
38

• Information use to for proactive planning and
  service improvement over time
• Local and state trend analysis of issues that
  potentially jeopardize individuals health and
  safety
• Benchmarking and developing strategies for change
  over time
• Making comparisons to national data trends and
  benchmarks

Key features of quality improvement
39

Examples of Quality Improvement
Domain Protection from Harm Regulations, policies and procedures Current QAQI Processes Remediation Quality Improvement
Person-Centered Indicators
People and family members report they understand the reporting system for critical incidents Statewide critical incident training sessions for individuals and families Human rights training requirements for direct support professionals (DSPs) Consumer and family survey Case manager monitoring Follow-up by case managers Statewide, county trends from consumer surveys
Provider Indicators
Provider staff are knowledgeable about and implement the incident management policies and procedures. Incident management training requirements for DSPs. DD certification process Provider Plan of Improvement Follow-up Immediate jeopardy Statewide trends from DD certification process
System Indicators
Statewide critical incident trends are reviewed and strategies for prevention are developed and implemented. Same as above Critical incident database Statewide critical incident trends
40
Systemic Quality Improvement Measures

• Comparing data from different QA processes is key
  to strategic planning
• Quality should be analyzed from a variety of
  perspectives
• (e.g., consumer surveys, licensing/certificati
  on, case management monitoring/service planning)
•  
• Some information is more beneficial is compared
  to other national benchmarks of quality
•  
• And in some instances it is more informative to
  provide the data in a context
• Total occurrences as compared to the total
  possible number, total population, etc.

41
Supports continuous improvement at all levels
Consumer survey
Re-affirms whats working well and/or makes
changes in services and supports
Person-centered planning
Individual
Critical incident
Risk planning
Case manager monitoring
42
Internal consumer survey trends
Quality committee CQI Strategies
Staff Training, prevention, root cause analysis,
changes in policies and procedures
Provider
Critical incidents
Quality review results
Performance measures
43
Consumer survey trends
Systemic
Critical incident trends
Statewide training, prevention, root cause
analysis, changes in policies and procedures
County, regional, statewide quality council, CQI
Strategies
Mortality review trends
Quality review trends
44

• Given the move towards quality management what
  are our immediate challenges and potential
  solutions for sustainability?

45
Improving the Sustainability ofPerson-Centered
Monitoring

• Improve the effectiveness and efficiency of
  current processes
• Integrate information (FL, PA)
• Develop internal QA systems
• Integrate quality assurance responsibilities
  across the system (MA)

46
Improve Sustainability

• Involve families and people with disabilities
  (PA)
• Improve up-front quality expectations upfront
  (PA)
• Increase transparency of QA systems and
  development of a demand for information (CT)
• Explore quality assurance for individual
  providers (UT, OR, NH)

47
Conclusions and Recommendations
48
Important Next Steps

• Place individual outcomes at the center of the
  system
• Enlist assistance of consumers and families
• Identify key areas of performance
• Create a quality management entity
• Make results available and accessible

49

• Develop uniform reporting of critical health and
  safety events
• Develop staff credentialing and expand training
  options
• Reassess roles and responsibilities of case
  managers
• Refine performance contracting

50

• Expand understanding of participant centered
  planning
• Develop a technical assistance capacity
• Implement risk management and health assessments
  (OR, MA, CA)
• Build integrated data systems (CA, FL, PA)
• Develop hotlines and ombudspersons

51
(No Transcript)
52
(No Transcript)
53
Lessons for Providers

• Develop internal quality improvement plans
• Work with states to streamline QA/QE procedures
• Continue to work to upgrade the status of direct
  support professionals
• Enlist people with disabilities and families
• Continue to train staff in person-centered
  principles
• Assume that quality assurance will become
  morecomprehensive and systematic

54
Final Words

• Beware the Continuous Improvement of Things
  Not Worth Improving
• W. Edwards Deming

CAUTION
55
Resources

• Publications
• Bradley, Valerie J. and Kimmich, Madeleine H.
  (Eds.), Quality Enhancement in Developmental
  Disabilities Challenges and Opportunities in a
  Changing World. (2003). Paul H. Brookes
  Publishing Company.
• Schalock, Robert L. (ED.), Quality of Life Volume
  I (Conceptualization and Measurement, 1996) and
  Volume II (Application to Persons with
  Disabilities, 1997). American Association on
  Mental Retardation (AAMR).
• Gardner, James F. and Nudler, Sylvia (EDs.),
  Quality Performance in Human Services
  Leadership, Values and Vision. (1999). Paul H.
  Brookes Publishing Company.
• U.S. Department of Health and Human Services,
  Office of th4e Assistant Secretary of Planning
  and Evaluation. Understanding Medicaid Come and
  Community Services A Primer. (2000).
• Quality Assurance for Individuals with
  Developmental Disabilities. Its Everybodys
  Business. (1990). Paul H. Brookes Publishing
  Company.

56

• Publications, continued
• Measure for Measure Person-centered Quality
  Assurance. The Proceedings of the Wingspread
  Conference, Racine, Wisconsin, October, 2000.
  Available at http//www.ncor.org/wingspread.html
• Centers for Medicare and Medicaid Services (CMS),
  U.S. Department of Health and Human Services. CMS
  Regional Office Protocol for Conducting Full
  Reviews of State Medicaid Home and
  Community-based Services Waiver Programs.
  Available at http//www.hcbs.org
• Web-sites
• HSRI.org qualitymall.org
• HCBS.org cms.hhs.gov