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

2. 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

3. 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.) –

4. 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.

5. 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

6. 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).

7. 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

8. 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

9. 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

10. 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

11. 9/19/2018
So where are we now?

12. 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

13. 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

14. 9/19/2018
Questions/Comments: