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

Human 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

Human Services Research Institute 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

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

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

Human Services Research Institute 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 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 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

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

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

Human Services Research Institute 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 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 Provider Capacity and Capabilities Availability of individual and agency providers Review of provider qualifications Monitoring of provider performance

Human Services Research Institute 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 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

Human Services Research Institute Participant Outcome and Satisfaction Participant outcomes Participant satisfaction

Human Services Research Institute 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….

Human Services Research Institute Continuous Quality Improvement Design Features Areas of focus, Outcomes, indicators Provider enrollment Rules, policies, Procedures Quality Improvement  Trends Analysis  Benchmarking  Strategic Planning Remediation  Real time tracking of incidents and follow-up  Analysis of specific trends  Plan of correction  Provider Qualification

Human Services Research Institute Developing a Quality Management Strategy Design Features Areas of focus, Outcomes, indicators Rules, policies, Procedures

Human Services Research Institute 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 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 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

Human Services Research Institute Design Features Areas of focus, Outcomes, indicators Provider enrollment Rules, policies, Procedures

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

Human Services Research Institute Examples of QA Processes or Measures Domain: Protection from HarmRegulations, policies and procedures Current 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 families  Human rights training requirements for direct support professionals (DSPs)  Consumer and family survey  Case 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 procedures  Web-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

Human Services Research Institute Design Features Areas of focus, Outcomes, indicators Provider enrollment Rules, policies, Procedures Remediation  Real time tracking of incidents and follow-up  Analysis of specific trends  Plan of correction  Provider Qualification

Human Services Research Institute 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 = Examples of Remediation Domain: Protection from HarmRegulations, policies and procedures Current 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 families  Human rights training requirements for direct support professionals (DSPs)  Consumer and family survey  Case 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 Improvement  Follow-up  Immediate 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 procedures  Web-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

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

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

Human Services Research Institute Design Features Areas of focus, Outcomes, indicators Provider enrollment Rules, policies, Procedures Quality Improvement  Trends Analysis  Benchmarking  Strategic Planning Remediation  Real time tracking of incidents and follow-up  Analysis of specific trends  Plan of correction  Provider Qualification

Human Services Research Institute 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 Key features of quality improvement

Human Services Research Institute = Domain: Protection from Harm Regulations, policies and procedures Current QAQI Processes RemediationQuality 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 families  Human rights training requirements for direct support professionals (DSPs)  Consumer and family survey  Case 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 Improvement  Follow-up  Immediate 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

Human Services Research Institute 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 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

Human Services Research Institute 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

Human Services Research Institute 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 trends Quality review trends

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

Human Services Research Institute Improving the Sustainability of Person-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 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

Human Services Research Institute 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

Human Services Research Institute 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 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 more comprehensive and systematic

Human Services Research Institute Final Words “ Beware the Continuous Improvement of Things Not Worth Improving ” W. Edwards Deming

Human Services Research Institute 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.

Human Services Research Institute Publications, continued Measure for Measure: Person-centered Quality Assurance. The Proceedings of the Wingspread Conference, Racine, Wisconsin, October, Available at 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 Web-sites: HSRI.org qualitymall.org HCBS.org cms.hhs.gov