The Quality Conundrum Achieving Safety, Health and Valued Outcomes

How Did We Get Here? Initial concentration on rudiments of custodial care Evolution of programmatic standards that reflected growth in our understanding of people’s needs and our own expertise Increased concern about the efficacy of our interventions Attention to the outcomes of services and supports from the perspective of the customer

Valued Outcomes Individualization Integration/ Inclusion Relationships/ Social Connections Health and Safety Personal Growth Choice and self- determination Dignity Consumer Satisfaction

Signs of Change in Performance Management No longer just better than the institution Rooted in outcomes Emphasis on enhancement Changing role of the state Changes in experiences of families and people with mental retardation Changes in accreditation approaches Outcomes Expectations Inclusion

More Signs of Change Movement away from prescriptive standards Emphasis on CQI Exploration of self-assessment Collaborative development of standards Inclusion of customer satisfaction Satisfaction CQI Consensus

The Two Faces of QA: One: Control

The Two Faces of QA: Two: Enhancement

Public Quality Assurance Responsibilities Assuring that individuals are free from abuse, neglect, and exploitation; Protecting the rights of individuals and families; Assuring accountability in the use of public dollars; Assuring that individuals have access to necessary professional services; Evaluating the effectiveness if service and supports; Assessing the performance of service providers

Changing Quality Landscape Exposure of fault-lines in the system (e.g., HCFA and the press) Expansion of supports to individuals on the waiting list Emergence of self-determination Olmstead decision Struggles with MIS applications Direct support staff shortages

Myths and Cautions Choice is the only thing that matters Health and safety are synonymous with outcomes Providers are ready for outcomes There is a correlation between “best practice” and consumer satisfaction”

Critical Constraints Drain of knowledgeable staff from public sector Consolidation of providers Management of multiple systems “Generic” approaches to quality Increasing gray areas in public jurisdiction Pressure from HCFA Lack of collaboration with sister agencies

Important Next Steps Place individual outcomes at the center of the system Enlist assistance of consumers and families Identify key areas of performance Link technology with need for information Look at the costs and benefits of existing approaches Make results available and accessible Get serious about uniform reporting of critical health and safety events

More Recommendations Develop Staff credentialing and expand training options Reassess roles and responsibilities of case managers Refine performance contracting Expand understanding of person- centered planning

Emergence of Performance Indicators First appeared in behavioral and acute care Provide some “cues” for managing these complex systems Highlight impact of cost containment Illuminate what’s working Provide early warning signs

Characteristics of Performance Indicators Reflect major organizational or system goals. Address issues that can be influenced by the organization or system Have face validity Point a direction Reflect rates or major events Related to associated standards

Consumer Involvement in Assuring Quality Choice among providers/ purchasing decisions Designing and refining QA mechanisms Grievance/appeals process Consumer satisfaction surveys Membership on policy-making board Telecommunications networks “Consumer Reports”

Health and Safety Imperatives Ensure adequate number of service coordinators Build individualized health and safety plans Screen and train employees Train individuals and families Increase federal funding Develop hotlines and ombudspersons

Continuous Quality Improvement Leadership at the senior level Engagement of multiple constituencies Identification of emerging issues and priorities Development of an benchmarks Identification of change strategies Measurement of progress

What Do You Do With the Information? Include at your web site Prepare annual reports to the legislature Develop provider profiles Use with sister agencies Monitor managed care initiatives Use in allocation decisions

Final Words “ Beware the Continuous Improvement of Things Not Worth Improving ” W. Edward Deming