odp community services quality management developing the administrative entity quality management...
TRANSCRIPT
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ODP Community Services Quality Management
Developing the Administrative Entity Quality Management Quarterly Report
WebExFebruary, 2010
Ann Ligi, ODP Quality Management Lead – EastJodie Enterline, ODP Quality Management Lead – West
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Learning Objectives
Explain AE QM Quarterly Report Expectations
Learn about Data Organization, Analysis and Reporting
Understand the Application of the PDCA Model
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AE Performance Objectives
AE QM Quarterly Report Includes all required elements Template is used Timely submission
Data Organization Tables and charts are used
PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis
Performance is monitored ongoing
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Reports Timeline
Reports Due 1st Q 2nd QAE submits QM Quarterly Report electronically to Regional Program Manager
April 30, 2010 July 31, 2010
Feedback to AE June 15, 2010 September 15, 2010
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Report Generation Timeline
Actions 1 2 3 4
Prior to QM Meeting
Retrieve data
Organize data (prepare tables, charts)
Generate DRAFT report
Provide to group prior to meeting
During QM Meeting
Discuss & interpret findings
Interpret & Analyze data; Identify patterns & trends; Apply C (check) of PDCA
Determine A (act) of PDCA; i.e.Maintain or Revise Action Plan
Determine PDCA Follow Up; Finalize draft report
After QM Meeting
Finalize report
Submit by due date 5
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AE QM Quarterly Report Template
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: Date: Submitted by:
Focus Area and Desired Outcome:
Objective:
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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ODP QM Quarterly Report Evaluation Tool
Show evaluation tool and go through the questions.
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Complete the top section of the Quarterly Report using information from the AE Annual QM Plan
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: ABC Date: April, 2010 Submitted by: ABC QM Manager
Focus Area and Desired Outcome: Safeguards People are free from restraint
Objective: Reduce Incidents of Restraint by 20% by December 31, 2010
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Number of restraints.Number of individuals restrained.Data Source: HCSIS – Data Warehouse
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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Performance Measures were identified in the AE Annual QM Plan
2010 QM Plan Administrative Entity Name: ABC Focus Area: Safeguards
GOAL OUTCOME TARGET OBJECTIVEPERFORMANCE MEASURES/ DATA
SOURCE(S)/FREQUENCY/RESPONSIBLE PERSON
People are safe and secure in their homes and communities
People are free from restraint.
Reduce Incidents of Restraint by 20% by December 31, 2010
Baseline:Calendar Year 2009 = 100 restraints 10 individuals
Number of restraints.Number of individuals restrained.
Data Source: HCSIS, Data Warehouse
Frequency: Monthly
Person Responsible: ABC QM Manager
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Transfer the Performance Measures from the QM Plan to the Quarterly Report
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: ABC Date: April, 2010 Submitted by: ABC QM Manager
Focus Area and Desired Outcome: SafeguardsPeople are free from restraints
Objective: Reduce Incidents of Restraint by 20% by December 31, 2010
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Number of restraints.Number of individuals restrained.Data Source: HCSIS – Data Warehouse
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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AE QM Quarterly Report: Findings and Analysis
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: Date: Submitted by:
Focus Area and Desired Outcome:
Objective:
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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Completing the Findings and Analysis Section
Organize data – table Graphically display the data Analyze the data (CHECK)
After review of the data, what did we conclude?
If we conclude that we are not on track to achieve our objective, then why? (barriers)
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AE QM Quarterly Report: PDCA Follow-up
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: Date: Submitted by:
Focus Area and Desired Outcome:
Objective:
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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Completing PDCA Follow-up Section
If you identified barriers to achieving your objective, identify what you are doing or will do, to overcome the barriers. (ACT) These should be actions/activities on your
Action Plan If you’re on track to reach your objective,
identify what activities will be taken to sustain achievement and continue progress.
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AE QM Quarterly Report: Key Stakeholder Involvement
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: Date: Submitted by:
Focus Area and Desired Outcome:
Objective:
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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Completing Key Stakeholder Involvement Section
Who are Key Stakeholders? Waiver participants, their family
members or representatives, and Waiver providers including SCOs.
What kind of “involvement”? Involved in the identification of local
quality management priorities Involved in QI activities (meetings,
planning, implementation, reporting etc.)
See Section 5.15 of the 09-10 AE Operating Agreement
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AE QM Quarterly Report: Reporting to the MH/MR Board of Directors
Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.
Administrative Entity: Date: Submitted by:
Focus Area and Desired Outcome:
Objective:
Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.
Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.
Describe how key stakeholders are involved in the achievement of QM Plan objectives.
Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.
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Completing the Reporting to the MH/MR Board of Directors section
Document how frequently you report QI activities to the Board of Directors.
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QUESTIONS?
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PLAN
DOCHECK
ACT
C
Quality Resource Group of Hospital Corporation of America---1992 20
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PDCA Model
Plan how the improvement will be accomplished. Write an action plan that specifies actions taken to achieve the annual target
objective.
Do it. Implement the improvement plan. This includes education of staff and management about the process change.
Check the effect of the improvement Collect and analyze data Identify lessons learned. Determine the success or failure of the plan.
Act Hold the gains or Re-strategize steps in action plan and implement them Continue to monitor and evaluate progress.
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Determine baseline performance
Analyze baseline data
Develop an Action Plan for the improvement
Implement the plan
The PDCA Cycle - PLAN
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The PDCA Cycle - DO
Once you have a PLAN……. Conduct training
Implement (Just Do It!)
Use a Data Collection Tool
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The PDCA Cycle - CHECK
Review and analyze the performance data
Did the improvement work or not? If not successful, what were the
barriers?
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The PDCA Cycle - ACT
Based on success or lack of success in achieving your objective, ACT to maintain gains or modify your plan
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QUESTIONS?
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Data Organization, Analysis and Reporting
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DATA
INFORMATION
KNOWLEDGEINFORMEDDECISIONS
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DATA - Organizing Data
Steps: 1. Retrieve data
2. Organize into a table
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DATA – Retrieve Data - Sources
HCSIS/Data Warehouse AE Data Collection Tools Surveys Comprised of individual cases, data
elements
See example
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ABC Communication Tracking Tool
Name: Date of ISP:
Information Reviewed
Check Appropriate Item
Complete, as Needed
Assessment/s Completed: Needed ? Indicate if Yes
(Date)
VerbalNon-verbal
Communication Needs, If Non-Verbal: Communication Supports/System NotesSystemTypeAvailableIn Working OrderRepair NeededUtilizedTraining NeededTraining Provided
________________
Follow up needed Yes/No04/11/23
Data Collection Tool ExampleABC Communication Tracking Tool -
ABC Communication Tracking Tool
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Aggregate the DataMultiple Cases/Month = Data
Draft 1-7-10
One case
done in month
All cases done in month
Data for that
month
July August September
# of individuals(# of ISPs)
# Non-Verbal
# w Comm. System 32
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DATA – Organize Data into Tables
Tables Columns
Categories Variables Time
Rows Individual cases Aggregate totals
See examples 33
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Example TableABC Primary Incidents FY 2008-2009
Incident Category July August Sep Oct Nov Dec Jan Feb Mar Apr May June Total
Abuse 21 22 19 23 21 17 23 17 25 30 27 12 257
Death 9 11 5 4 6 9 7 6 15 8 13 4 97
Emergency Closure 2 2 0 2 1 6 1 51 4 2 0 0 71
Emergency Room Visit 90 93 80 72 82 72 75 77 81 75 82 85 964
Fire 7 1 6 11 4 10 4 10 5 4 10 7 79
Hospitalization 42 30 37 35 24 44 41 38 31 41 41 27 431
Individual To Individual Abuse 34 40 37 27 32 36 39 34 46 37 48 43 453
Injury Requiring Treatment Beyond First Aid 9 1 6 9 4 9 6 7 8 9 7 4 79
Law Enforcement Activity 10 22 10 10 15 18 13 10 12 20 18 14 172
Medication Error 88 90 95 83 64 97 77 82 87 77 91 84 1,015
Missing Person 8 9 1 4 4 11 8 11 8 13 16 22 115
Misuse of Funds 7 2 12 28 5 4 4 5 2 5 1 3 78
Neglect 11 13 7 4 2 5 6 1 16 11 10 1 87
Psychiatric Hospitalization 10 8 14 11 12 14 15 10 12 19 13 16 154
Reportable Disease 0 1 1 0 0 0 1 2 0 0 1 2 8
Rights Violation 0 2 0 5 1 1 0 3 7 5 4 1 29
Suicide Attempt 0 0 0 0 0 0 0 0 0 0 0 0 0
Restraint 67 62 69 81 63 49 71 86 61 62 64 53 788
Total 415 409 399 409 340 402 391 450 420 418 446 378 4,877
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Example Table – 1st Q of Calendar Year
Measure Jan ‘10 Feb’10
Mar‘10
YTD Total1st Q
Restraints 13 11 14 38
Ind. restrained 4 5 4 5
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Organized Data - Tables
Measure Jan ‘10 Feb’10
Mar‘10
YTD Total1st Q
Restraints 13 11 14 38
Ind. restrained 4 5 4 5
Note: YTD Total is not 13 because we count each unique individual once.Finding: 5 individuals, 38 restraints
Some individuals experienced multiple restraints during the first quarter. 36
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INFORMATION – Transforming Data into Information
Create a chart/graph of the data Histogram/Bar Chart Line Chart/Run Chart
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INFORMATION - Bar Chart
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INFORMATION – Line Chart
# of Restraints and Persons Restrained
J an – March 2010
1311
14
45 5
0
2.5
5
7.5
10
12.5
15
J an Feb Mar
Fre
qu
en
cy
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INFORMATION – Bar Chart
ABC # of Restraints J anuary 2009 to March 2010
8
10
5
7
12
13
15
8
4
5
7
6
5
3
4
0
2
4
6
8
10
12
14
16
J an-09 Feb-09 Mar -09 Apr -09 May-09 J un-09 J ul -09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 J an-10 Feb-10 Mar -10
M onth
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INFORMATION - Line Chart
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KNOWLEDGE: Findings and Analysis
Based on the review of the Information, what can we conclude? Be aware of the potential to misinterpret data
Are we on track to reach our objective?
If we are not on track to reach our objective, do we have information that can help us to identify why we are not on track?
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Example Findings and Analysis
See sample report
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INFORMED DECISIONS – Recommendations and Follow -up
As a result of the analysis, identify recommendations and follow-up actions to be taken
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Example Recommendations and Follow-up
See separate sample report document
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WRAP UP
AE QM Quarterly Report Includes all required elements Template is used Timely submission
Data Organization Tables and charts are used
PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis
Performance is monitored ongoing
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QUESTIONS?
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Next Steps
WebEx will be posted Technical Assistance
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For further Technical Assistance Contact:
Ann Ligi ODP QM Lead – East [email protected] 570-443-4218 Jodie Enterline ODP QM Lead – West
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