Survey Redesign Division of Quality Improvement 9/19/2018 Survey Redesign Division of Quality Improvement Provider Association Meeting June 20, 2016

Purpose Meet mission for timing/frequency of survey activity 9/19/2018 Purpose Meet mission for timing/frequency of survey activity Maintain the quality and consistency of reviews while enhancing efficiencies Create effective sustainable review process Integrate new standards and review of outcomes affecting quality of life Provide simple and transparent information sharing for OPWDD, stakeholders and providers Facilitate quality improvement activities ANTICIPATED BENEFITS: Manual and paper-based systems do not effectively support current or future OPWDD initiatives Workload relief/reduction Minimal use of interim and short-term solutions in favor of effective and sustainable systems/processes Enhance consistency, coordination and integration of DQI activities statewide Simple and transparent to administer for OPWDD, stakeholder and providers

Current Survey Process 9/19/2018 Current Survey Process Site visits are conducted (over 10,000 annually) Discrete survey protocols are utilized for each function Sample selection/methods to review services are discreet resulting in a review limited in scope Ability to analyze provider performance is limited Protocols (17 protocols are in existence) (e.g., Incident Management, Safety/ physical plant, MSC, etc.) –

Components of Redesign 9/19/2018 Components of Redesign Protocols AQP Process IT Training Putting survey design into place is not the success. Ineffective processes can be put into place. It is that it helps us to be better.

Redesign DQI still visits every site 9/19/2018 Redesign DQI still visits every site Builds from AQP Domains indicators Routinizes HCBS settings standards review Streamlines protocols and review activities Incorporates targeted/risk-based review approach Routine focus on outcomes Modernized review documentation, report creation and administrative review modernized Protocol Completion also creates your Exit Conference Form and Statement of Deficiencies Review activities completed by IMU will not be duplicated Centralization of review activities Area Directors have the survey information at fingertips

Survey Protocols Site Review Person-Centered Review Agency Review 9/19/2018 Survey Protocols Existing protocols will be streamlined into three types of reviews: Site Review Person-Centered Review Agency Review The Bureau of Program Certification (BPC) is required to enter survey deficiency data into the federal Automated Survey Processing Environment (ASPEN) system for Intermediate Care Facilities (ICFs).

Approach Each protocol will capture key elements: 9/19/2018 Approach Each protocol will capture key elements: Regulatory requirements Core activities (Must review) Consistency in expectations & activities conducted Health and safety (Routine and High Risk) Protocol standards and related IT allow for better collection of findings data and identification of trends

Site Review Only one “type” of site review Focus: 9/19/2018 Site Review Only one “type” of site review Focus: Comply with Mental Hygiene Law Site Characteristics, Fire and Environmental Safety Safeguards Focused review of areas that pose greatest risk to individuals Observation and Conversation are Key! Does not include review of all services Customized for program type as identified by Program ID # Requires Gathering of specific information Discussion/Entrance Topics, Documents to request Provider Responsiveness Identifies specific conditions present in the site related to people’s needs Records Observation periods Allows for upload of documents Rationale for Not Met results in a SOD and/or ECF, including option for IJ SOD If-then protocol standards Allows for entry of findings at any time for any reason “Partial Review”, e.g. Complaint visits Special f/u due to incidents Monitoring visits Important to maintain a full record and analysis of agency performance

Person Centered Review (PCR) 9/19/2018 Person Centered Review (PCR) Review of any and all services a person receives from all provider agencies providing their services Includes service/site specific requirements related to: Person Centered Service planning Service delivery Safeguards: minimize risks Rights, health, safeguards, behavioral supports, protections Quality of life Standards displayed based on person in the sample: Protocol “knows” based on TABS info

Agency Review Centralized review of: 9/19/2018 Agency Review Centralized review of: Regulatory and quality expectations designed, implemented and managed at the agency level Sample verification of compliance for selected regulatory requirements Agency practices and strategies that influence quality outcomes: Workforce Quality improvement planning and strategies Community Connections Agency Management Centralizes review of agency systems and quality strategies that influence outcomes for agency stakeholders

9/19/2018 So where are we now?

Protocols Site Protocol written ITS building First to be ready 9/19/2018 Protocols Site Protocol written ITS building First to be ready Other Protocols to be built on what learned Person Standards identified Services identified Guidance in process IT Requirements in process Agency Initial information to ITS

9/19/2018 Timeline Resources and Training on Survey Redesign to all stakeholders: written materials, WebEx, etc. Summer 2016 DQI Training: Review Activities Provider WebEx 9/2016 Implement Site Review 10/03/16 10/2016 Implement PCR 11/01/16 11/2016 Implement Agency Review 12/2016

9/19/2018 Questions/Comments: quality@opwdd.ny.gov