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@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 Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

5. Current factors in services and supports contributing to changes in Quality Assurance and improvement efforts…. Human Services Research Institute

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 Human Services Research Institute

7. 23States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services … Gary Smith, HSRI, 2003 Human Services Research Institute

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) Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

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) • Individual’s funds • Health and medication • Community inclusion and integration • Independence and autonomy • Choice and decision-making Human Services Research Institute

12. CMS is also opening up the discussion about quality….. The Quality Framework Human Services Research Institute

13. Participant access Participant safeguards rights and responsibilities Provider capacity and capabilities Participant outcomes and satisfaction Quality Participant rights and responsibilities System performance Participant-centered service planning and delivery Areas of Focus HCBS Quality Framework Human Services Research Institute

14. Participant Access • Information and Referral • Intake and Eligibility • User-friendly processes • Eligibility determination • Referral to community services • Individualization of services • Prompt initiation Human Services Research Institute

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 Human Services Research Institute

16. Provider Capacity and Capabilities • Availability of individual and agency providers • Review of provider qualifications • Monitoring of providerperformance Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

19. Participant Outcome and Satisfaction • Participant outcomes • Participant satisfaction Human Services Research Institute

20. System Performance • Conduct system performance appraisals • Support quality improvement • Ensure cultural competency • Support participant & stakeholder involvement • Maintain financial integrity Human Services Research Institute

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23. Continuous Quality Improvement Close the loop • Information from quality assurance drives decision making! Therefore…. Human Services Research Institute

24. Continuous Quality Improvement Human Services Research Institute

25. Developing a Quality Management Strategy Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

28. Examples of outcomes and Indicators Human Services Research Institute

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30. Discovery • QA Processes or Measures • Key feature: • Must be able to collect the information reliably across the entire system! Human Services Research Institute

31. Examples of QA Processes or Measures Human Services Research Institute

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33. Remediation • Key Features • Access to “real time” information • Be able to respond to and correct serious health and safety issues when they occur Human Services Research Institute

34. = Examples of Remediation Human Services Research Institute

35. Quality Improvement or Closing the Loop Who needs the information and why?? Human Services Research Institute

36. Information from quality assurance should be used to drive decision making! Therefore…. • Information should be readily available and easily accessible Human Services Research Institute

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38. Key features of quality improvement • 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 Human Services Research Institute

39. = Examples of Quality Improvement Human Services Research Institute

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/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. Human Services Research Institute

41. Supports continuous improvement at all levels Consumer survey Re-affirms what’s working well and/or makes changes in services and supports Person-centered planning Individual Critical incident Risk planning Case manager monitoring Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

44. Given the move towards quality management what are our immediate challenges and potential solutions for sustainability? Human Services Research Institute

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) Human Services Research Institute

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) Human Services Research Institute

47. Conclusions and Recommendations

48. 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 Important Next Steps Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute