1. Sandhills Center LME Quality Management Program

2. Quality Management Program Statement of Purpose To ensure services (internal and external) are appropriately monitored and continuously improved. An emphasis on communication, interdepartmental, structured communication and total agency teamwork. Integrate Quality Management into the entire organization.

3. Design To comply with URAC Standards, DMH/DD/SAS and DMA Rules and incorporates the Centers for Medicare and Medicaid Services (CMS) Quality Framework. The Quality Framework includes the following functions for design of the Quality Management Program: Discovery; Remediation and Continuous Improvement.

4. Discovery – collecting data and direct participant experience in order to assess the ongoing implementation of the program, identifying strengths and weaknesses. Remediation – Taking action to remedy specific concerns that are identified Continuous improvement – utilizing data, data and more data to engage in actions that emphasize continuous improvement.

5. PDCA Additionally, the Quality Management Program utilizes the Plan, Do, Check, Act (PDCA) Quality Improvement Model. Plan – Analyze the problem, establish a solution plan and set goals Do – Implement the solution Check – Evaluate the solution Act – Monitor for continuous improvement and implement system change. The QM Program balances Quality Assurance and Quality Improvement activities in that Quality Assurance activities inform and spark the Quality Improvement process.

6. Oversight and Responsibility of the QM Plan The Board of Directors has ultimate responsibility for oversight and effectiveness of the QM Program. The CEO is administratively responsible for the direction and overall functioning of the QM Program and ensures allocation of adequate resources and staffing. The Chief Clinical Officer/Medical Director is responsible for oversight of the QM Program and advises on clinical issues. The QM Director manages the day to day operations related to the implementation of the QM Program. The Board of Directors reviews and approves QM Plan annually The Board of Directors receives quarterly reports of all QM activities including Satisfaction Survey results, Complaints and Incidents.

7. Quality Management Committee & QM Structure Committee structure Four (4) major committees: Quality Management Care Management/Utilization Management Health Network Customer Services

8. QM Program Committees Responsibilities Oversight of the day to day operations of the Quality Management Program and compliance with rules, regulations and URAC standards; Define performance measures to ensure compliance and review data related to the indicators; Communicate activities and findings back to the Quality Management Committee through Executive Summaries and Task Logs.

9. Quality Management Committee Serve as the main conduit of change for the organization. Provide oversight of the Sandhills Service Management System, operations, functions, processes and practices. Provide a forum for problem solving and addressing processes for improvement.

10. Quality Management Committee Is made up of Department Heads from each section Is chaired by the Medical Director Identifies quality indicators, measures and activities as required by contracts with DMA and DMH/DD/SAS Establishment of performance benchmarks for all internal and external quality indicators

11. Quality Management Committee Activities Review Care Management/UM, Health Network and Customer Services task logs and Executive Summaries; Review and promote further discussion of data analysis; Review and recommend approval of Policies & Procedures, Decision Support Tools, Scripts; Review satisfaction data for improvement opportunities; Approval and monitoring of program specific QIPs; Reviews QM Plan annually

12. Quality Management Committee Activities (cont’d) Monitor Access to LME Services; Monitor Complaints and Appeals; Provide oversight of monitoring of network providers and recommend sanctions, as necessary; Review, approve and track Marketing and Communication Materials; Monitor Compliance with delegation policies and procedures;

13. Quality Management Committee Activities (cont’d) Ensure all staff, the Network Leadership Council, Global CQI Committee, Consumer and Family Advisory Council and Board of Directors have a mechanism to provide input into the Quality Management Program; and.Promotes use of data driven material across all departments

14. Quality Improvement Projects Exemplify the process of continuous quality improvement; Allow for data collection, measurement and analysis that indicates problems that may require corrective action and improvement. Each Program maintains at least two QIPs at any given time: At least one project must focus on error reduction and/or member safety and At least one project must focus on members, that relates to specified key indicators or quality and involves a senior clinical staff member if the QIP is clinical in nature.

15. Quality Improvement Projects All QIPs have to meet URAC requirements and 2 have to be approved by DMA for the first year of the contract with a 3 rd one added the second year. QM staff tracks QIPs for 1 year after closure to ensure achieved benchmarks are maintained.

16. Global CQI Committee Sandhills Center has a Global Continuous Quality Improvement Committee which is a sub-committee of the Quality Management Committee Is chaired and co-chaired by providers Its membership will include representation from all provider groups

17. Global CQI Committee The group will analyze data, identify barriers and assist in implementing interventions to improve quality of care through out Sandhills. This group will make recommendations to the Sandhills Quality Management Committee

18. QM Monitoring types Complaints Incident Reports Quality of Care Concerns Gold Star Performance Profile Reviews - Initial - Routine -Preferred -Exceptional -Gold Star

19. QM Monitoring types Licensed Independent Practitioners (LIPs) -Preliminary - Preferred The tools utilized for these reviews are on Sandhills Center website and on the Division of Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services website.

20. Quality of Care Concerns QOC concerns can come from any of the groups referenced previously as well as from external sources Each reviewed by QM Director and Medical Director and disposition determined Can be referred to the Clinical/Financial Risk Management Committee or to Program Integrity

21. Quality Management Program Evaluation Annual Evaluation Comprehensive analysis of:  Accomplishments;  Committee activities;  Results of Quality Improvement activities; and  Trending of indicator data. May result in the proposal of new activities or establishment/revision of Policies & Procedures. Assists in the identification and establishment of new priorities/goals for the Quality Management Program.

22. Incident Reporting Requirements IRIS a web based incident reporting system for reporting and documenting Level II and III incidents involving members receiving MH/I/DD/SAS services. Information relating to IRIS is found at http://www.ncdhhs.gov/mhddsas/, click on IRIS Technical Manual

23. Incident Reporting Requirements Purpose of IRIS is to ensure that serious adverse events are addressed quickly And analyzed for ways to prevent future occurrences and improve the service system There are three levels of incidents Level I addressed internally, NOT entered into IRIS and reported to Sandhills Center on a quarterly basis

24. Incident Reporting Requirements Level II Incidents must be documented and submitted in IRIS within 72 hours consecutive hours of learning of the incident and addressed internally by the provider Deaths from natural causes are Level II incidents

25. Incident Reporting Requirements Level III incidents must be submitted in IRIS within 72 consecutive hours of occurrence and verbally reported to Sandhills Center. All deaths from unknown causes are Level III incidents. Once additional information is learned, it must be entered into IRIS as well

26. Incident Reporting Requirements If IRIS is unavailable at any time, providers must still meet the time lines for submission of an incident by faxing a paper copy of the incident report to the proper agencies.

27. Incident Reporting Incident types: Under the care of a provider ( that means has received service within 90days prior to the incident) Allegations of Abuse, Neglect or Exploitation Consumer Injury

28. Incident Reporting Con’t Medication Errors Absences Reminders Level I Quarterly Summaries are due by the 10 th of the month following the end of the quarter.

29. Incident Reporting Contacts Angie Kivett Sandhills Center 108 West Walker Ave Asheboro, NC 27203 telephone - 336-389-6358 fax 336-625-3661 or angiek@sandhillscenter.org

30. Incident Reporting Contacts con’t DMH/DD/SAS Quality Management Team Complaint Intake Unit 3004 Mail Service Center Raleigh, NC 27600-3004 Fax: 919-715-3604 Voice 919-733-0696 contactDMHQuality@dhhs.nc.gov

31. Incident Reporting Contacts con’t Division of Health Services Regulations 27111 Mail Service Center Raleigh, NC 27511-2711 Fax 919-715-7724 Phone 200-624-3004 or Rita.Horton@dhhs.nc.gov