1. CAP & PDSA Expectations for 2018
Laura Jasso, LCSW
Brian Rosemond, RN, BSN
Janina Vazquez

2. Objectives
Clarify what services categories will require a Corrective Action Plan (CAP) vs. Plan-Do- Study-Act (PDSA)
Explore the difference in AA vs Provider roles in the CAP/PDSA process
Discuss AA responsibilities for 2018 CAP/PDSA submission
Explain vision for CAPs/PDSAs beyond 2018
View update 2018 CAP template
Critic PDSA from 2017
Review upcoming CAP/PDSA training opportunities
9/1/2019

3. CAP/PDSA Expectations
2018 CAPs and PDSAs
CAPs and PDSAs post Germane Monitoring will continue for 2018
Both the CAP and PDSA templates have been updated
Service Category
CAP/PDSA Expectations
Universal Standards
CAPs required for all indicators below 100%
* For eligibility indicators below 100%, a CAP is required, and 90-day submissions, showing results of 10 chart pulls per every 30 days (This process must continue until eligibility indicator reaches 100%).
OAHS, OH, HIA, MCM
2-3 PDSAs required for each service category for any indicator(s) at or below 50% (HRSA/HAB measures need to be prioritized).
NMCM, EIS, MH, LPAP, Home Health Care, HCBHS, Hospice Services, MNT, SA –O , EFA, HE/RR, Outreach Services, and SA (residential)
One CAP required per service category for any one (1) indicator per service category at or below 50%.
9/1/2019

4. 2018 CAP Expectations Universal Standards (US)
CAP expectations for US will remain the same
A CAP must be submitted for any indicator that scored below 100% on the US
US CAPs must be submitted with supporting documentation
Policies & Procedures
Chart Pulls
9/1/2019

5. 2018 PDSA Expectations PDSAs
2-3 PDSAs will be required for indicators that scored at or below 50% for the following service categories:
OAHS,
Oral Health,
Health Insurance Assistance, and
Medical Case Management
*HRSA/HAB measures (noted on the DSHS Monitoring Tools) must be prioritized when selecting indicators for PDSAs.
9/1/2019

6. 2018 CAPs (not US)
CAPs
One CAP will be required for one indicator that scored at or below 50% for the remaining service categories:
LPAP; Home Health Care; Home and Community- Based Health Services; Hospice Services; MNT; SA (Outpatient Care); EFA; HE/RR; Outreach Services; SA Services (residential), NMCM, MH*; and EIS*.
*For EIS and MH CAPs, providers do not need to include indicators that scored above 50%, but showed less than a 20% improvement.
9/1/2019

7. AA vs Provider Expectations
AA Staff Responsibilities
Select format/template for chart pull submission
Ensure CAP/PDSA are submitted to DSHS in a timely manner (tracking moving from RN consultant to AA)
Ensure all US CAPs are have supporting documentation
Complete preliminary review of CAPs/PDSAs with feedback before submission to DSHS
Ensure providers understand chart pull expectations for eligibility indicators
Follow-up with providers about 30 day chart pulls
Provide any additional TA for CAPs/PDSAs post Germane Webinars
9/1/2019

8. Provider Expectations
Provider Responsibilities
Must be the parties completing the CAPs and PDSAs
Must be the parties pulling the chart abstractions
Client will need to have been seen in the previous 30 days for the current chart abstraction
Providers can pull charts using their EMR or their Practice Management System
Must identify at least one CAP/PDSA Subject Matter Expert (SME) within their agency
9/1/2019

9. Changes for Administrative Agencies (AA)s
Expect expanded monitoring by DSHS
AAs need to make appropriate adjustments for AA staff to be able to track and follow up on all CAPs and PDSAs
AAs need to ensure monitoring activates are being paid for correctly
Chart reviews = Administration
Follow-up of CAPs and PDSAs = QM
9/1/2019

10. New CAP Template 9/1/2019 CORRECTIVE ACTION PLAN
Provider Agency: ______________________________ Date Submitted by Provider:
Indicator Number on Provider Report: __________________________________
1. FINDINGS
Indicate outcome indicator standard and finding(s)
2. CORRECTIVE ACTION
Describe change in policy, procedure, eligibility chart pulls, or process to correct the issue
3. NAME & TITLE OF PERSON(S) Accountable for change implementation
4. TARGET IMPLEMENTATIO N DATE
5. FOLLOW-UP PROCESS
Describe how changes will be monitored or incorporated into an internal QI Process
6. NAME & TITLE OF PERSON(S) Accountable for follow-up
7. DATA SOURCE FOR DOCUMENTATI ON OF FOLLOW-UP
Standard
Outcome Indicator
9/1/2019

11. Cap Template cont…
Dispute (must submit supporting documentation)
AA Comments/ Feedback
DSHS Comments
Administrative Agency Reviewer: __________________ Date _________
DSHS: Reviewed and Approved by ___________________________________ Date _______________
9/1/2019

12. PDSA Example 1
9/1/2019

13. PDSA Example 1 cont…
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14. PDSA Example 2
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15. PDSA Example 2 cont…
9/1/2019

16. PDSA Tracking Checklist
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17. PDSA Tracking Checklist Pg 2
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18. PSDA tips for Success
Please read the PDSAs before you send them to DSHS
Stay on top of the due dates and track the PDSA’s at your level
Call DSHS to discuss a problematic PDSAs
Please use a checklist to make sure the PDSA has been checked before sent to DSHS
For the final PDSA the agency needs to completely answer the narrative
9/1/2019

19. Training Opportunities
Germane Solutions will be conducting four CAP/PDSA trainings for providers and AA staff
February 14th, :00 AM - 11:00 AM CST 
April 11th, :00 AM - 11:00 AM CST 
May 9th, :00 AM - 11:00 AM CST 
June 13th, :00 AM - 11:00 AM CST 
Additional Resources
Institute for Healthcare Improvement (IHI)
HRSA Ryan White HIV/AIDS Program Center for Quality Improvement and Innovation (CQII)
UTHSC CS&E: Clinical Safety and Effectiveness Course
Target Center
HRSA Ryan White Website on Quality of Care
9/1/2019

20. Questions
9/1/2019

21. Thank you Laura.Potter@dshs.texas.gov Brian.Rosemond@dshs.texas.gov
9/1/2019