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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
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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
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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
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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
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Current factors in services and supports contributing to changes in Quality Assurance and improvement
efforts….
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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
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23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …
Gary Smith, HSRI, 2003
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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)
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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
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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
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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
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CMS is also opening up the discussion about quality…..
The Quality Framework
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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
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Participant Access
Information and Referral Intake and Eligibility
– User-friendly processes– Eligibility determination– Referral to community services– Individualization of services– Prompt initiation
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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
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Provider Capacity and Capabilities
Availability of individual and agency providers
Review of provider qualifications
Monitoring of providerperformance
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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
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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
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Participant Outcome and Satisfaction
Participant outcomes Participant satisfaction
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System Performance
Conduct system performance appraisals
Support quality improvement Ensure cultural competency Support participant & stakeholder
involvement Maintain financial integrity
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Continuous Quality Improvement
Close the loop
Information from quality assurance drives decision making! Therefore….
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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
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Developing a Quality Management Strategy
Design Features•Areas of focus, Outcomes, indicators•Rules, policies, Procedures
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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
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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
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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
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DiscoveryQuality reviewsConsumer surveyIncident management
Design Features•Areas of focus, Outcomes, indicators•Provider enrollment •Rules, policies, Procedures
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Discovery
QA Processes or Measures
Key feature:
Must be able to collect the information reliably across the entire system!
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Examples of QA Processes or MeasuresDomain: Protection from Harm Regulations, policies and
proceduresCurrent 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 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
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DiscoveryQuality reviewsConsumer surveyIncident management
Design Features•Areas of focus, Outcomes, indicators•Provider enrollment •Rules, policies, Procedures
RemediationReal time tracking of incidents and follow-upAnalysis of specific trendsPlan of correctionProvider Qualification
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Remediation
Key Features
Access to “real time” information
Be able to respond to and correct serious health and safety issues when they occur
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Examples of RemediationDomain: Protection from Harm Regulations, policies and
proceduresCurrent 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 familiesHuman rights training requirements for direct support professionals (DSPs)
Consumer and family surveyCase 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 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
Statewide critical incident trends are reviewed and strategies for prevention are developed and implemented.
Same as above Critical incident database
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Quality Improvement or Closing the Loop
Who needs the information and why??
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Information from quality assurance should be used to drive decision making! Therefore….
Information should be readily available
and easily accessible
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DiscoveryLicensingConsumer surveyIncident management
Design Features•Areas of focus, Outcomes, indicators•Provider enrollment •Rules, policies, Procedures
Quality ImprovementTrendsAnalysisBenchmarkingStrategic Planning
RemediationReal time tracking of incidents and follow-upAnalysis of specific trendsPlan of correctionProvider Qualification
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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
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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 familiesHuman rights training requirements for direct support professionals (DSPs)
Consumer and family surveyCase 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 ImprovementFollow-upImmediate 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
Examples of Quality Improvement
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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.
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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
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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
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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
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Given the move towards quality management what are our immediate challenges and
potential solutions for sustainability?
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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)
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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)
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Conclusions and Recommendations
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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
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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
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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
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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
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Final Words
“Beware the Continuous Improvement of Things Not Worth Improving”
W. Edwards Deming
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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.
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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