(Anderson-Cherokee
Community Enrichment ServiceS)
QUALITY MANAGEMENT
PLAN
FY2011-2012
Submitted
by: Approved
by:
Karen
Pate, CPHQ Allyn
Lang, Executive Director
Chief
Administrative Officer Cathy
Newman, Chair,
ACCESS Board of Trustees
TABLE OF CONTENTS
|
Item |
Page |
|
Overview
and Center Mission Statement |
3 |
|
The
Quality Management Plan Functions |
|
|
4 |
|
5 |
|
6 |
|
7 |
|
Quality
Management Program Description |
9 |
|
Quality Management Processes |
14 |
|
Stakeholders Involvement in Quality
Management |
17 |
|
Measuring,
Assessing, and Improving Service Capacity, Access to Services, and Continuity
of Services |
19 |
|
Measuring,
Assessing, and Improving Organizational and Authority Functions |
20 |
|
Measuring,
Assessing, and Improving Services Provided |
22 |
|
Measuring,
Assessing, and Reducing Incidents on Consumer Abuse, Neglect, and
Exploitation |
25 |
|
Quality
Improvement and Oversight of Prescribing of Psychoactive and Other
Medications |
27 |
|
TIMA
Quality Improvement Process to Ensure Appropriate Implementation |
27 |
|
Monitoring
the Effectiveness of the Quality Management Plan |
29 |
|
Key
Indicators, FY2011-2012 |
30 |
|
Attachment
– Utilization Management Plan |
31 |
Overview
ACCESS is dedicated
to providing quality care for all consumers in a safe, clean, and wholesome
environment. Through continuous
assessment and improvement of systems and processes, ACCESS improves its
services to consumers, stakeholders, and the community.
The performance
improvement program provides an objective and systematic approach to the
quality of services provided by ACCESS.
Improvement activities are focused on process and outcome indicators
intended to demonstrate increased access and choice while preserving or
enhancing the quality of services and supports that are delivered in the most
cost-effective and efficient manner. An integrated and collaborative approach
increases the probability of desired consumer outcomes by assessing and
improving governance, managerial, clinical, and support processes.
ACCESS Mission,
Vision, Core Values
The foundation of the
ACCESS Quality Management Plan is the Center’s Mission, Vision, and Core Values
Statement, articulated by the Board. A task force consisting of consumers,
family members, ACCESS employees and Board members formulated these overarching
principles. The recommendations of the
task force were subsequently adopted by the ACCESS Board of Trustees in 1999.
Mission: People can count on ACCESS
v to work hand in hand
with those around us to assure a choice of effective, efficient programs and
caregivers; and
v to offer excellent
services that enhance quality of life.
Vision: ACCESS will be the number one choice
in Anderson and Cherokee Counties for people with brain and behavioral
disorders.
Values: Respect for the individual
Service to the customer
Respect
for the dignity of risk
Pursuit
of excellence in all that we say and do
Commitment to
personal integrity in every facet of every relationship
Mission of ACCESS
Quality Management Program
The overall mission
is to assure continuous performance improvement toward the delivery of quality
care that is efficient, cost effective, and consistent with the mission of
ACCESS. When issues in client care and service delivery can be anticipated, it
is essential that quality improvement activities of a proactive nature
occur. Quality improvement is integral
to improving client outcomes and service delivery, and it is necessary that it
be integrated in all programs at all levels.
Problem identification is an important aspect of quality improvement,
but its importance is based upon the effectiveness of the subsequent process of
problem resolution. The ACCESS Quality
Management Program promotes delivery of quality care through leadership
involvement in assessment and improvement activities, in order to:
v Provide an effective
mechanism to design, measure, assess, and improve the performance of
the system.
v Improve the
quality of care through service monitoring, resolution of problems, and
ongoing pursuit of opportunities to improve care.
v Implement a
preventive approach
toward problems and risk factors, and to monitor actions taken to assure that
desired results are achieved and sustained.
v Promote communication about performance
improvement activities among all stakeholders.
v Promote safety and to
prevent liability
through systematic monitoring of the environment and center activities.
Governance
and Leadership
Ultimate
responsibility for the processes designed to monitor the quality of care,
outcomes, and important processes and functions performed by internal and
external providers is retained by governance and leadership who ensure the
Quality Management Program is implemented system-wide and that oversight of the
Quality Management Program is provided by professionals with adequate and
appropriate experience in quality management.
·
The
leadership of ACCESS serves as the locus of consumer and family input, quality
management, and other data used for decision-making.
·
Leaders
serve as agents for change. They set
expectations and priorities for systemic improvement activities designed to
improve organizational and clinical outcomes and processes.
·
The
leadership allocates adequate resources for improvement and assures that staff
are educated about assessing and improving processes that contribute to
achieving organizational outcomes.
·
Leadership
entrusts operational managers with assuring that all staff participate in the
Quality Management Plan by being aware of the outcomes of quality management
activities in their service areas and are given opportunities to suggest
improvement activities.
·
Leadership
fosters communication among individuals and components of the organization to
improve the coordination of activities.
Both internal and external providers are
expected to assess the delivery of services in their areas and to implement
changes to improve service delivery. Many quality improvement activities
occur at the service delivery level.
Staff persons identify an opportunity for improvement, analyze the
problem, and make recommendations to managers for change.
ACCESS CENTER-WIDE GOALS
I. Regulatory
Compliance
To comply with regulations
of relevant oversight and funding bodies.
II. Quality Services
To provide quality
services to consumers, family members, and the community.
III. Increased
Efficiencies
To work within
declining resources, to stretch resources through collaboration with others,
and to seek out new sources of revenues, using strategies for increased
efficiency.
IV. Effective
Infrastructure
To maintain and
enhance an effective infrastructure and to develop resources that support the
Center in fulfillment of its mission.
V. Accurate, Reliable
Data
To implement and
maintain data resources that prove accurate and reliable, for use in
decision-making and monitoring.
Quality
Management Goals
Goal 1: Support ACCESS in meeting all applicable regulatory requirements and standards.
Objectives:
·
Review
any new applicable Texas Administrative Codes.
·
Review
State contract requirements regularly.
·
Review
ACCESS’ policies and procedures as needed.
Measurable
Outcomes:
·
All
new applicable Texas Administrative Codes are reviewed within thirty days.
·
A
review of requirements for State Contracts is completed monthly.
·
ACCESS
Policies and Procedures are reviewed on an ongoing basis to assure conformity
with contracts, codes, and laws.
Goal 2: Monitor and evaluate system processes to support the Center in providing quality services.
Objectives
·
Complete
100% of DSHS, DADS, DFPS audits within the required time frame.
·
Submit
any Plans of Improvement on time and carry out improvement steps within
specified time frame.
·
Monitor
outcomes from consumer surveys, public forums, or other stakeholder input.
·
Report
results of audits, plans of improvement, and stakeholder input to Executive
Director and Executive Council.
·
Complete
all studies as required by State Contract.
Measurable Outcomes:
·
All
DSHS, DADS, DFPS audits are completed within specified time frames.
·
Plans
of Improvement are submitted and completed within specified time frames.
·
Results
of audits, plans of improvement, and stakeholder input are reported to
Executive Director and Executive Council.
·
All
studies required by State Contract are completed on time.
Goal 3: Develop processes for efficient communication with staff and other stakeholders.
Objectives:
·
Submit
outcomes on Performance Contract measures to the Executive Council.
·
Keep
Board of Trustees informed of Performance Contract outcomes and results of
Quality Management and Corporate Compliance activities.
·
Report
on contract performance to Sponsors once a year.
·
Offer
training for staff at least annually.
Measurable Outcomes
·
Performance
Contract outcomes are submitted to Executive Council monthly, or as indicated.
·
A
report is given to the Board of Trustees annually on Performance Contract
results and results of Quality Management and Corporate Compliance activities.
·
A
report is presented to Sponsors once a year.
·
Training
is offered to staff once a year.
Goal 4: Implement continuous improvement practices.
Objectives
·
Measurable
results will be incorporated into plans for improvement.
·
Available
benchmarks will be reviewed by Quality Management Committees.
Measurable Outcomes
·
Results
from monitoring activities are utilized for continuous improvement.
·
Benchmarks
available from State reports, ETBHN Committees, and online resources are
reviewed by Quality Management Committees.
Quality Management
Program Description
Board of Trustees
The Board of Trustees
has ultimate responsibility for the policies and governance of the Center. The Board delegates to the Executive Director
the responsibility for development of procedures and practices to carry out the
Board policies. The Board of Trustees is
accountable to the sponsoring entities and to the communities served:
·
to
assure quality services to eligible consumers
·
to
seek input and involvement of all stakeholders
·
to
plan for the future
·
to
maintain viability of the center through its oversight of budget, policies, and
the Executive Director
Executive Council
The senior leaders of
the Center serve on the Executive Council:
Executive Director, Chief Administrative Officer, and Chief Program
Officer. The Executive Council meets at least monthly and may review any of the
following quality management items:
·
Any
new legislative items that impact the Center
·
Any
new Texas Administrative Codes that impact the Center
·
Performance
Contract requirements
·
Program
status reports
·
Cost
Accounting reports
·
Data
Warehouse reports
·
Audit
reports
·
Productivity
indicators
·
Risk
assessments
·
Management
reports
·
Financial
reports
·
Procedures
for review and revision
The Chief
Administrative Officer also serves as the Center’s Corporate Compliance Officer
and is charged with operating and monitoring the compliance program to assure
that services, including Medicaid and Medicare, are needed, authorized,
appropriately documented and of benefit to the consumer and that Center staff
receive mandated compliance training.
Quality Management Committee
The Quality
Management Committee is structured to minimize duplication of effort and to
maximize information flow across internal and external providers and
services. Findings are analyzed to
identify trend, patterns, and opportunities for improvement. Intensive assessment is initiated when
statistical analysis indicates undesirable variations in performance and
mechanisms are established to effectively resolve identified problems or
improve existing processes.
Because the same
people are involved, three committee functions are performed concurrently. The
Quality Management Committee for ACCESS is also the Corporate Compliance
Committee and the Utilization Management Committee. Membership includes:
Executive Director, Chief Administrative Officer, Chief Program Officer,
Quality Management Coordinator/Consumer Relations Officer, Coordinator of IDD
Essential Services, Coordinator of MH Community Programs, Reimbursement
Coordinator, Human Resources Coordinator, Clinical Records Coordinator,
Fiscal/Data Reporting Manager, Fiscal Services/Accounting Manager, Safety
Officer, and the MIS Coordinator.
The Committee meets
quarterly or more often, with focus on clinical/programmatic oversight
activities that address issues unique to DSHS and/or DADS. In addition to the
formal quarterly meetings, ad hoc Quality Improvement Teams may meet to address
interim quality concerns. This allows
for the additional participation of program management staff and facilitates
“real-time” planning and problem resolution for program/service-specific issues
as they are identified.
In its function as
Quality Management committee, members perform the following activities:
·
Review
audits and other monitoring activities
·
Participate
in self-assessment activities
·
Prioritize
improvement activities
·
Develop,
implement, monitor, and review plans of improvement
·
Integrate
quality efforts among service areas
·
Oversee
implementation of the goals and objectives of the Center and for the Quality
Management Plan
·
Assist
with development of annual Incentive Plan
·
Review
updates and revisions to the Quality Management Plan, the Local Service Area
Plan, and other plans for the Center
In its function as
Corporate Compliance Committee, members regularly review the following:
·
Incident
Log (abuse and neglect allegations, complaints, accidents, in-house investigations,
deaths, incidents)
·
Human
Resource reports (background checks, personnel actions, staff training issues)
·
Program
Reports (survey results, program data)
·
Administration
Reports (billing reports, data security and integrity issues, productivity
reports)
·
Cost
Accounting Reports
In its function as
Utilization Management Committee, members are responsible to perform the
following:
·
Identify
trends, outliers, and problems for the Center, using Data Warehouse and
internal database reports
·
Establish
practice and provider guidelines consistent with State fidelity requirements
·
Review
and approve processes for making resource allocation determinations
·
Review
results of ETBHN Regional UM Committee data reports to identify and address
areas of concern
Regional Utilization
Management Committee
Member Centers of
East Texas Behavioral Healthcare Network send representatives to the Regional
Utilization Management Committee. This
committee meets the membership requirements outlined in the UM Guidelines and
has developed a set of by-laws to govern the committee. The committee members meet at quarterly
intervals either in Lufkin, or through videoconference. The physician, Mark Janes, M.D. Medical
Director for Bluebonnet Trails Community MHMR, and through contract, for
ACCESS, meets with the Committee. The
regional group prepares and reviews UM data from each of the member
centers. The data provides comparison
among centers that are geographically proximate and that share common
concerns. Data analysis includes
identification of outliers and trends, both in program areas and in cost
centers. Discussion among the
representatives may also address practice issues or guidelines for providers. Clinical determinations and appeals may be
brought to the committee for consideration, upon request from a member center.
Professional Review
Committee
Professional Review
Committee is called as needed and provides a mechanism for clinical review of
sentinel events and oversight for issues related to the quality and appropriateness
of service. This committee carries out
the duties as assigned in the ACCESS policies and procedures.
Safety and Disaster
Committee
The Safety Committee
meetings are held as called by the Chair.
Membership consists of site representatives from each ACCESS
location. The committee performs the
following activities;
·
Addresses
safety and preventive maintenance issues
·
Follows
up on steps taken to remedy identified problems
·
Analyzes
risk factors for disaster/emergency preparedness
·
Reviews
compliance with the Safety Plan and the Disaster/Emergency Plan
·
Reviews
available data, including infection control and other risk management issues
which may emerge, to identify trends
·
Reviews
and updates the Safety Plan and the Disaster/Emergency Plan
Regional Planning
Network Advisory Committee
Member centers of the
East Texas Behavioral Healthcare Network have established a Regional Planning
Network Advisory Committee (RPNAC), which meets quarterly in Lufkin, Texas or
by videoconference. The RPNAC contributes
to the development and content of the Network Plan, including the process of
Local Planning and Network Development, which assures appropriate procurement
of goods and services and reviews and makes recommendations that consider
public input, best value and client care issues to ensure consumer choice and
best use of public money. The RPNAC
performs a variety of other functions, including the following:
·
Reviews
aggregate data from the member centers on a variety of topics, in order to
identify trends
·
Makes
recommendations to the centers based on their reviews
·
Performs
evaluations of various providers (in-house or contracted) for a program or
service, in order to determine best value, upon request of a member center
·
Performs
review and evaluation activities for provider networks of centers
·
Provides
review of local and regional planning activities.
·
As
part of the Local Planning and Network Development planning process, provides a framework for a regional
assessment of and comparison of each member Center’s community stakeholders
satisfaction with Center practices and service delivery, and includes feedback
from consumers, advocates, law enforcement, hospitals and referral sources.
Each center sends one
or more representatives for mental health, as well as a staff liaison. Results
of RPNAC activities are reviewed by the Quality Management Committee and its
recommendations, if any, are also reported to the ACCESS Board of Trustees.
Responsibilities of
Quality Management Staff
·
Coordinate
planning activities, which include the following:
o
Local
Service Area Plan
o
Center
Goals and Objectives
o
Quality
Management Plan
o
Local
Network Development Plan
o
Jail
Diversion Plan
o
Crisis
Services Plan
o
ADA
Transition Plan
o
Abuse
Neglect Reduction Plan
o
Consumer
Benefits Assistance Plan
o
Safety
and Disaster Plan
·
Verify
accuracy of data submitted to State
·
Review
of provider treatment to ensure compliance with DSHS evidence-based practices
by:
o
Monitoring
implementation of Texas Implementation of Medication Algorithms (TIMA) and
o
Monitoring
implementation of Resiliency & Disease Management (R&DM) through
fidelity reviews and other routine monitoring activities to determine the
accuracy of assessments and treatment planning
·
Monitor
compliance with Medicaid (or other pay source) requirements for billing
·
Complete
reports required by State Authorities
·
Monitor
confidentiality, consumer rights, complaints, and abuse and neglect issues
·
Monitor
the quality of crisis services, access to services, service delivery, and
continuity of services
·
Identify
and address other clinical and organizational risk issues to improve
performance of provider services and outcomes for individuals served
·
Provide
technical assistance to providers to improve the quality and accountability of
provider services
·
Ensure,
if applicable, that Health Department
inspections are scheduled for programs serving meals to ten (10) or more
consumers
·
Ensures
that all deaths of ACCESS consumers are reviewed in compliance with state
regulations.
Management Team
Many of the functions
related to quality and utilization management are also reviewed on a daily
basis by the members of the Executive Council and Management Team. The Management Team consists of all Service
Area and Administrative Function Coordinators, who are also members of the
Center’s Quality Management Committee.
Critical data are
reviewed to ensure timely response to and resolution of risk issues. Areas reviewed include, but are not limited
to, the following: abuse, neglect, or
exploitation; consumer and staff incidents and injuries; medication errors;
employee Workers Compensation events; vehicle usage and accidents; rights
violations; complaints’ deaths’ serious health related incidents; infection
control/infectious disease incidents; and results of on-site
safety/environmental inspections.
Other resources committed to quality
improvement practices include Center employees with responsibilities for
reviewing internal accounting data, reimbursement functions, employee training
information, program compliance, review and audit of the Medicaid
Administrative Claiming data, clinical records reviews, and credentialing.
Quality Management
Processes
The ACCESS QM Program
is integrated with other organizational functions, including areas of service delivery,
fiscal and business functions, data and information systems, utilization
management, contracting, and human resources. ACCESS continually seeks to
assess itself through methods that are appropriate, timely, efficient and
reliable. The ACCESS QM Program is based on a continuous quality improvement
model with elements that focus on the design, monitoring, analysis, and
improvement of processes that are integrated throughout the organization.
The following are
essential stages in ACCESS’ continuous quality improvement processes:
·
Design
of processes that:
o
Are
consistent with Center’s mission, vision and values
o
Meet
requirements of State Authorities
o
Reflect
unique cultural, linguistic, demographic, or other characteristics of local
service area
o
Meet
needs of local service area
·
Monitoring
of performance, by review of
o
Performance
indicators related to standards
o
Risk
factors
o
Organizational
performance indicators
o
Stakeholder
satisfaction
·
Analysis
of current performance, through
o
Level
of performance
o
Effectiveness
of processes
o
Needs
for improvement
·
Improve
or sustain performance, through
o
Establishing
baseline criteria
o
Developing
written plans of improvement when criteria are not met
o
Implementing
plans of improvement, with collaboration of all parties involved
o
Following
up on plans of improvement
Data Collection
Data is available
through the following resources:
o
Local
database (Anasazi software), including:
·
Server
reports
·
Services
provided reports
·
Billing
reports
o
ACCESS
financial software (Fundware)
·
General
Ledger
·
Accounts
Payable and Receivable
·
Cost
Accounting
o
Regional
data from East Texas Behavioral Healthcare Network, comparing measures from
member centers, including but not limited to the following:
o
Program
evaluations
o
Server
productivity
o
Cost
of services
o
Statewide
and center specific data from MBOW (State data warehouse), including but not
limited to the following:
·
Performance
contract measures
·
Assessments
measures
·
Financial
measures
o
Encounter
data
o
CARE/WebCARE
data
o
Critical
Issues data
o
Local
risk assessments
o
Data
verification audits and results
o
State
Consumer Satisfaction Surveys, if available
o
Satisfaction
data gathered from interaction with community leaders and complaints to the
Consumer Relations Officer, as well as from surveys gathered through the Local
Planning and Network Development planning processes
o
State
audits of programs and authority areas
o
Local
productivity reports
Analysis and
Evaluation of Data
Quantitative analysis
is conducted using audit tools to look for presence or absence of
information. Qualitative analysis is
performed by measuring actual results against quality indicators. Statistical analysis and evaluation are
performed depending on the type of data involved. Monitoring systems, processes, and outcomes
is part of the process of analysis and evaluation. Improvement activities are
enacted when substandard performance is identified, or a negative trend
identified, and continued data collection and analysis is made until acceptable
performance is obtained.
Sanctions are imposed
for continued non-compliance and may include any of the following actions: written warnings to personnel file,
ineligibility for financial increases or other financial incentives,
ineligibility for promotion, ineligibility for continued referrals, probation,
administrative reassignment of personnel, and/or termination of a contract or
from employment. The desired outcome is that evaluation of data will show that
the Center’s service delivery systems provide appropriate, efficient, and
cost-effective services.
Identification of
Trends
Strengths and areas
of need are identified from analyzing data collected. Strengths within a program are assessed for
applicability to positively influence programs.
Areas of needs within a program require either a formal or informal plan
of improvement, with strategies for improvement.
Best Practices and
Evidence-Based Service Delivery
ACCESS participates
in Best Practices identified in its Performance Contract with DSHS. Through
collaboration with East Texas Behavioral Healthcare Network, the Center also
has the opportunity to learn about best practices and innovative programs from
other centers in the region.
ACCESS implemented
service packages outlined in Resiliency and Disease Management, a treatment
model based on research and evidence about the best practices for service
delivery. QM staff monitor fidelity of
implementation through routine chart reviews to ensure compliance with RDM
processes.
Benchmarking
The use of statewide
data from the Data Warehouse is a valuable tool for benchmarking with other
Centers. Other sources for benchmarking include the ETBHN reports, publications
in the behavioral health field, and State reports.
Trends identified in
reports for local data are reviewed by the Executive Council and the Quality
Management Committee. Benchmarks are
identified, with the objective of improving affected areas. Recommendations from the committees are
reviewed by the appropriate Service Area Managers/Coordinators, and in some
cases by the Executive Council, for approval and implementation.
Stakeholder
Involvement in Quality Management
ACCESS endorses the
involvement of consumers, advocates, family members, and other stakeholders in
the design, delivery, implementation, and evaluation of services.
The Board of Trustees
includes opportunity for Citizen Comment at their meetings. Additionally, time is set aside for “consumer
focus” at many of the meetings. At these
times, a presentation is made to the Board about some program or activity for
consumers; consumers or family often participate in these presentations.
Consumers and other
stakeholders participate in the Regional Planning Network Advisory Committee,
composed of representatives from each member center of the East Texas
Behavioral Healthcare Network.
ACCESS has a consumer
feedback phone line that is answered by the ACCESS Consumer Relations Officer
and is a local call throughout the entire service area. This number is
displayed in all service locations and on business-size cards distributed to
consumers. Information received through
these calls is relayed to the appropriate Service Area Manager/Coordinator or
to the Executive Director.
The Consumer
Relations Officer investigates all reported problems, complaints, and rights
violations, and reports any findings to the Executive Director and other
relevant members of management. These
and other items are included in the Corporate Compliance Log, which is reviewed
by Committee.
The Center provides
support and assistance to the Cherokee County Peer Support Group, the local
consumer-operated peer support program. Members provide feedback on issues to
the Consumer Relations Officer, who relays information to appropriate staff.
Members also participate in the development and review of local planning
efforts.
Public forums on
Mental Health and Developmental Disabilities Issues are held in each county
each year for individuals and their families who receive services, in order to
discuss ways the Center might better serve their needs.
Reports are presented
annually to the Sponsors of ACCESS:
Anderson County, Cherokee County, City of Jacksonville, and City of Palestine. Feedback is received from these governmental
entities during these presentations.
Information
may be shared with internal/external providers and stakeholders through both
formal (audit results, written reports, and program evaluations) and informal
means (on-the-spot problem solving, discussions, and meetings).
Local Consumer Satisfaction Surveys are available in
lobby/waiting area at service sites. A Suggestion Box is located in each lobby.
Comments/suggestions are reviewed and acted upon.
State Mental Health Consumer and Family Satisfaction
Surveys for adults and for children are distributed, when available, to
consumers. Results are reviewed by management.
Focused Consumer Interviews or Surveys may be used at
intervals to solicit information about a particular service area or
population. Results will be provided to
the Executive Director, who may provide a summary of findings to management
with recommendations for action.
Measuring, Assessing
and Improving
Service Capacity,
Access to Services, and Continuity of Services
ACCESS has open
screening times in each clinic, where people can walk in for a screening
without an appointment. This brief
initial screening “screens out” those whose needs would better be met through
services of another agency or community resource. These people are given information about how
to contact other resources. The initial
visit “screens in” those who may meet the priority population the Center
serves, and these people are scheduled for intake.
The assessment
process uses the TRAG, which identifies the Recommended Level of Care. In most cases the recommended level becomes
the level of care authorized. However,
sometimes a consumer chooses a less intense level of care.
The following items
are monitored by Service Area Management and Quality Management staff, in order
to evaluate service capacity, access to services, service delivery, continuity
of services, and quality of crisis services:
·
The
length of time between screening and intake
·
The
length of time between intake and initial service delivery
·
No
show and cancellation rates
·
Override
rates (LOC-A compared to LOC-R)
·
Server
productivity (direct service time)
·
Hospital
beddays for State Mental Health Facilities and for local psychiatric beds on
contract with the center
·
Completion
of hospital pre-admission screenings
·
Completion
of aftercare/continuity of care functions after hospital discharges
·
Unit
service costs
·
Outlier
information
Local information is
compared to targets set by DSHS and/or DADS and
by ACCESS and to benchmarking information from ETBHN and other centers,
when available. The statewide database
(MBOW) has facilitated benchmarking by making data available on a variety of
measures for all centers.
Measuring, Assessing,
and Improving
Organizational and
Authority Outcomes
ACCESS assesses organizational and authority
outcomes through a variety of measures. Once an area has been determined
to be an area of need, action plans can be developed for improvement in that
area. Following are some of the reports and indicators used to measure
and assess organizational and authority outcomes
Security Risk analysis (HIPAA)
- An analysis is
completed at least annually by MIS staff about computer security issues,
relevant to HIPAA and information systems data integrity.
- An action plan
is developed to correct any identified issues, and the plan is reviewed
in quarterly Corporate Compliance Meetings.
Cost Accounting Reports
- Executive
Council and Corporate Compliance Committee review the Cost Accounting reports
quarterly.
o Outliers on the report are analyzed for possible corrective action.
Encounter Data
- Executive
Council and Corporate Compliance Committee review reports on Encounter
Data quarterly.
- Outliers on the
report are analyzed for possible corrective action.
State Consumer Satisfaction Surveys
- Results of
statewide satisfaction surveys for adults and children, when available,
are reviewed by Corporate Compliance Committee and Local Planning and
Advisory Committees on a quarterly basis.
Performance Contract Measures from CARE and
Data Warehouse
- Executive
Council, Management staff, QM staff, and the QM Committee review key
indicators from the Performance Contract and Data Warehouse reports.
- Areas not
meeting requirements are analyzed for possible corrective action.
Local Financial Reports.
- Monthly reports
on revenues and expenses, and a balance sheet are prepared for Board of
Trustees and Executive Staff and reviewed at the Board meetings
Monitoring of contracted services
- Monitoring
is performed to ensure continuous quality services to consumers receiving
contracted services.
- Annual
documentation training is provided to contracted staff to ensure
appropriate services are provided to the consumer, current standards are
implemented, and adequate services are provided according to current
performance contract measures.
- Deficiencies
observed are reported to the Executive Director and in some cases, to the
Executive Council for review and action.
Pharmacy and purchasing reports from ETBHN
- ACCESS
achieves cost reduction through collaboration in ETBHN.
- The
ETBHN pharmacy reduces medication costs. Pharmacy reports are reviewed by
the billing and purchasing staff.
- Quarterly
Pharmacy Reports are reviewed by the Regional Utilization Management
Committee, Regional Planning Network Advisory Committee, and the ACCESS
Utilization Management Committee.
- The
ETBHN purchasing plan reduces cost of equipment and supplies. The
purchases are reviewed by local purchasing and accounts payable.
Mystery Customer Project
o
To
gain insight into agency responsiveness and access to care, ETBHN member centers
make mystery customer phone calls quarterly to other centers’ offices.
o
Calls
are scored on basic tenets of customer service, and the results are shared with
all ETBHN Centers. To ensure continued courtesy and ease of access for
consumers, results are also shared with front-office staff and supervisors, as
well as with the Executive Council and the Quality Management Committee.
Measuring, Assessing
and Improving
Services Provided
ACCESS assesses service outcomes through a
variety of measures. Once an area has been determined to be an area of
need, action plans can be developed for improvement in that area.
Following are some of the reports and indicators used to measure and assess
service outcomes.
Data Warehouse Business Objects Reports and
Prompts, such as, but not limited to, the following:
- Service
Package Minimum Hours
- Ohio
Scales Completion Rate
- UM
Appropriateness
- UM
Completion
- General
Revenue Earned
- Potential
Lost Medicaid
- Assessments
Set to Expire
- Served
But Not Assessed
- Server
and Service Mix Drill
- Follow-up
Service Report for Clients Discharged
- Follow-up
Service Report for Closed Assignments
- Rejection
Report
- Campus
Based Assignments for a Specific Period
- Service
Detail Report
- Crisis
Community Linkage Report
- Crisis
Activity Report
CARE/WebCARE Data Reports, such as, but not
limited to, the following:
- RDM
Assessments Summary
- Monthly
entry into Ansazi is reconciled in CARE system
- Hospital
Funding Report
- Readmissions
Report
- MH
Monthly Outcomes
- Expired
TRAG Report
- TRAG
auto closures Report
Anasazi Reports, such as, but not limited to,
the following:
o Denial/Pending Claims
Report
o Exception Report
o Assessment Listing
Report
o Client Services
Detail Report
o Suspense Report
Fidelity Review Audits for R&DM
- Audits
to check for structures in place.
- Monthly
audits of services for fidelity to the R&DM model.
Data Verification Audits
- Samples
of encounter data are checked against local documentation
- Medicaid-eligible
services are checked for Medicaid documentation.
- Subset
samples are submitted for desk review by State.
Reports on Credentialing of Staff
o Credentialing
records are maintained by the Human Resources Department.
o The
Corporate Compliance Committee reviews the status of credentials for staff for
whom credentialing is required. This review includes monitoring of
provider competencies for serving persons with co-occurring psychiatric and
substance use disorders (COPSD).
Reports on Training of Staff
o Staff assigned to
complete the TRAG will achieve a passing score on the in-house competency test,
prior to assuming those duties.
o Staff assigned to
on-call will achieve a passing score on the in-house competency test, prior to
assuming those duties.
o Staff will complete
the mandatory on-line training annually, including training on
abuse/neglect/exploitation, and on consumer rights protection.
o Staff will complete
other mandatory training as required by the position.
Medicaid Audits
o In-house 100%
pre-billing audits to assure that billed services are eligible. Results
of audits are presented to management team for review and to providers for any
needed corrections, prior to billing.
o State audits of paid
Medicaid claims
New Generation Medication Audits
o In-house audits to
track changes in CARE
o State audits as
scheduled
Crisis Service Delivery Audits
o
QM
staff daily review crisis hotline calls to ensure they are properly coded as to
type and that response times meet requirements.
o
QM
staff review crisis data in the internal data system, as well as in the Data
Warehouse, to ensure crisis follow-up contacts and community linkages are
occurring as required.
o
QM
staff provide technical assistance and training to MCOT and other staff performing
crisis functions.
o
Reports
on crisis activities and MCOT implementation are presented to the ACCESS Board
of Trustees, as well as to the Utilization Management Committee.
COPSD Monitoring Activities:
o
QM
staff monitor Data Warehouse reports on improvements in clinical functioning
related to Co-occurring Psychiatric and Substance Use Disorders (COPSD)
o
QM
staff monitor for evidence of appropriate treatment response during routine
clinical record reviews to be sure that a person with COPSD receives services
that address both disorders
o
Results
are presented to Quality Management Committee
IT Monitoring Services
o All Servers are
rebooted weekly
o Antivirus software
checked weekly and complete virus sweep run monthly
o
Bandwidth
monitored daily to identify usage trends and identify problems.
o
All
data is backed up daily to offsite FTP server location.
o
All
backups checked daily. The backup tapes
are taken to the bank safety deposit box weekly.
Safety Measures and Disaster Preparedness
o
The
Safety Committee conducts on-site walk-through inspections of ACCESS sites to
reduce and prevent injury. The Committee’s report is submitted to the
Executive Council, Management Team, and site managers for required corrections.
Reports of activities and findings are reviewed by the Corporate Compliance
Committee.
o Follow-up monitoring
is done by Safety Officer to determine that deficiencies have been corrected.
o The Safety Committee
and Corporate Compliance Committee review Incident Reports to determine trends
inconsistent with the safe practices and operation of the agency’s physical
locations and vehicles. Trends are noted and reported to Executive
Council for recommendation, and follow-up action is required.
o The committee reviews
disaster and emergency preparedness periodically and reports concerns, if any,
to the Corporate Compliance Committee.
Measuring, Assessing,
and Reducing
Consumer Abuse,
Neglect, and Exploitation
·
Reports on Client Abuse and Neglect
o
All reports from DPRS are reviewed by the Executive Director, the
Chief Administrative Officer, Chief Program Officer, and the appropriate
Service Area Manager.
o
Staff perform the Client Abuse and Neglect Record System (CANRS)
data entry and maintain a log of all reported incidents. The log contains the
date, provider, type, and finding for each entry.
o
Quarterly, the data is examined by the Corporate Compliance
Committee to look for trends. If trends are found, the data is referred to the
relevant Service Area Manager for corrective action. Corrective action and
follow-up, if needed, are reported back to the Corporate Compliance
Committee.
o
All employees receive training in prevention of abuse, neglect,
and exploitation as new hires, in annual refresher training, and at other
times, when review activities indicate a need for additional refresher
training.
o
All consumers receive notification of their rights, as well as
information on reporting abuse, neglect, or exploitation, at their intake to
services, and at least annually thereafter.
o
The ACCESS Administrative Procedures require that any employee
accused of client abuse, neglect or exploitation be placed on administrative
leave until completion of the investigation by DPRS. The employee may return to
work if the DPRS finding is that the allegation is either unconfirmed or
unfounded.
o
If the finding is confirmed, disciplinary action is taken as
outlined in ACCESS Procedures, as follows:
“Disciplinary action shall
include the following appropriate penalties for employees or agents:
Class I Abuse:
termination of employment, or of agent's contract.
Class II Abuse:
First Violation:
Minimum action: One (1) day on suspension.
Maximum action: Termination of employment.
Second Violation: Termination of employment, or of agent's
contract.
Class III Abuse:
First Violation:
Minimum action: A written reprimand
by the Service Area Director which shall become part of the employee's
personnel file or agent's consultant file.