overview of quality assurance and enhancement

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 Disabilities

June Rowe Human Services Research Institute

[email protected]

Human Services Research InstituteHuman Services Research Institute

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


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

Some More Definitions


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


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

efforts….


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


23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …

Gary Smith, HSRI, 2003


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)


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


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

CQI

Consensus


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)Individual’s funds Health and medication Community inclusion and integration Independence and autonomy Choice and decision-making


CMS is also opening up the discussion about quality…..

The Quality Framework


HCBS Quality Framework

rights and responsibiliti

es

Areas of Focus

Participant access

Provider capacity

and capabilities

Participantsafeguards

Participant outcomes and satisfaction

System performan

ce Participant-centered

service planning and

delivery

Participant rights and

responsibilities

QualityQuality


Participant Access

Information and Referral Intake and Eligibility

– User-friendly processes– Eligibility determination– Referral to community services– Individualization of services– Prompt initiation


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


Provider Capacity and Capabilities

Availability of individual and agency providers

Review of provider qualifications

Monitoring of providerperformance


Participant SafeguardsPrevention 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


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 process

and grievance mechanisms


Participant Outcome and Satisfaction

Participant outcomes Participant satisfaction


System Performance

Conduct system performance appraisals

Support quality improvement Ensure cultural competency Support participant & stakeholder

involvement Maintain financial integrity


Continuous Quality Improvement

Close the loop

Information from quality assurance drives decision making! Therefore….


Continuous Quality Improvement

DiscoveryQuality reviewsConsumer surveyIncident management

Design Features•Areas of focus, Outcomes, indicators•Provider enrollment •Rules, policies, Procedures

Quality ImprovementTrends AnalysisBenchmarkingStrategic Planning

RemediationReal time tracking of incidents and follow-upAnalysis of specific trendsPlan of correctionProvider Qualification


Developing a Quality Management Strategy

Design Features•Areas of focus, Outcomes, indicators•Rules, policies, Procedures


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


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


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.

Examples of outcomes and Indicators


Discovery

QA Processes or Measures

Key feature:

Must be able to collect the information reliably across the entire system!


Examples of QA Processes or MeasuresDomain: Protection from Harm Regulations, policies and

proceduresCurrent QAQI Processes



Statewide critical incident training sessions for individuals and familiesHuman rights training requirements for direct support professionals (DSPs)

Consumer and family surveyCase 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 proceduresWeb-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


Remediation

Key Features

Access to “real time” information

Be able to respond to and correct serious health and safety issues when they occur


Examples of RemediationDomain: Protection from Harm Regulations, policies and

proceduresCurrent QAQI Processes

Remediation





Follow-up by case managers

Provider Indicators




Provider Plan of ImprovementFollow-upImmediate 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 proceduresWeb-based incident reporting system

Critical incident database

“Real Time” tracking of critical incidents

System Indicators




Quality Improvement or Closing the Loop

Who needs the information and why??


Information from quality assurance should be used to drive decision making! Therefore….

Information should be readily available

and easily accessible


DiscoveryLicensingConsumer surveyIncident management


Quality ImprovementTrendsAnalysisBenchmarkingStrategic Planning



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 timeMaking comparisons to national data trends and benchmarks

Key features of quality improvement


Domain: Protection from Harm

Regulations, policies and procedures

Current QAQI Processes

Remediation Quality Improvement





Follow-up by case managers

Statewide, county trends from consumer surveys

Provider Indicators




Provider Plan of ImprovementFollow-upImmediate jeopardy

Statewide trends from DD certification process

System Indicators



Statewide critical incident trends

Examples of Quality Improvement


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/certification, 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.


Individual

Consumer survey

Critical incident

Case manager monitoring

Risk planning

Person-centered planning

Re-affirms what’s working well and/or makes changes in services and supports

Supports continuous improvement at all levels


Provider

Internal consumer survey trends

Critical incidents

Performance measures

Quality review results

Staff Training, prevention, root cause analysis, changes in policies and procedures

Quality committee & CQI Strategies


Systemic

Consumer survey trends

Critical incident trends

Statewide training, prevention, root cause analysis, changes in policies and procedures

County, regional, statewide quality council, CQI Strategies

Mortality review trendsQuality review trends


Given the move towards quality management what are our immediate challenges and

potential solutions for sustainability?


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)


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)

Conclusions and Recommendations


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


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


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


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


Final Words

“Beware the Continuous Improvement of Things Not Worth Improving”

W. Edwards Deming


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. It’s Everybody’s Business. (1990). Paul H. Brookes Publishing Company.


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

overview of quality assurance and enhancement

Documents

provision of services

quality framework

overview of quality

use of quality data

quality health care

definitionsquality assurance

total number of people

annual physical exam