Performance and Quality Improvement, 7 07, ppt
- 1. QUALITY IMPROVEMENT: UNDERSTANDING THE PROCESS House of New Hope 1/2008
- 2. Benefits of a QI Process Old View of QI: • Adversarial: “what’s wrong” • “No news is good news” • Use process to catch mistakes and omissions early • Do it because required to • Helps to improve audit results 1/2008
- 3. Benefits of a QI Process New View: • “Nobody is perfect”-information on “how we are doing” is essential • Identifies patterns and trends • Eliminates gaps • Reduces agency risks • Assists in establishing priorities in service delivery • Defines “best practices” • Helps to define training needs • Provides data to make management decisions around services 1/2008
- 4. What is Quality Improvement? • Quality Improvement: a structured process that selectively identifies and improves all aspects of care and service on an ongoing basis through the use of disciplined inquiry, teamwork and targeted actions. 1/2008
- 5. Agency Quality Improvement Plan Elements: • Records Review: compliance and quality • Health and Safety • Input from Persons Served: Satisfaction surveys • Utilization Review (efficient use of services) • Risk Management • Outcomes: Performance Indicators 1/2008
- 6. What Makes Quality Improvement Plans Effective? • Staff and Administrative Ownership o It’s everyone’s responsibility o Belief in the process: use of data to make decisions • Feedback on the process o Ability to see it’s effectiveness • Strategic Planning o Ability to apply what’s been learned to present and future decisions 1/2008
- 7. Compliance Focus ODJFS o Is it in the record? o Did you complete it on time? ODMH o Is the service necessary? o Are your interventions appropriate? o Are your interventions effective? 1/2008
- 8. Compliance Focus CARF • How are you doing? (Data Collection) • How do you know? (Performance Indicators) • Can you demonstrate why you made a particular decision? (Evidence based practices; management by data) 1/2008
- 9. Types of Review • Clinical Records Review o Assures completion of required documents • Qualitative Peer Review Assures quality documentation Addresses Medical Necessity (established need for services) o Addresses principals of good practice Continuity of Care Integrated Services 1/2008
- 10. Selection Criteria • Length of Care: 30 to 60 days 90 to 270 days 270 days or more Discharge Hospitalization o Representative of all staff and programs o Random o Integrity: Prohibition of self review 1/2008
- 11. QI Process Forms • Each record will be reviewed for clinical completeness and quality of documentation Reviewer Teams • no less than two persons to a team; • no reviewing of own record Record Review • Agreement on ratings • Positive Constructive Feedback 1/2008
- 12. Clinical Records Review Compliance categories needing Correction • C/C: Compliant and Complete-(contains all required elements and completed within required time frames • C/I: Compliant/Incomplete-Compliant, such as form is present, but may be missing elements. • N/I: Non-compliant/Incomplete-information is not present, requires completion 1/2008
- 13. Compliance Categories not able to be Corrected N/C: Non-compliant, complete-form is present but not completed within required timeframe (i.e. cannot be corrected) N/A: Not applicable-use ONLY when time frames or circumstances do not require completion e.g. Assessment not complete: youth in care for 20 days—rating is N/A 1/2008
- 14. Data Collection Process • Reviewer Team completes record review • Completed review is turned in to Director of Care Management • Staff requested to make corrections as indicated • Corrections completed by designated time frame • Identify next set of records for review 1/2008
- 15. Reporting Process • Results of reviews are reported in aggregate on a quarterly basis • Action steps for system improvement are identified • Reviewed by staff, management, board of trustees • Results are continuously monitored to identify effectiveness of changes • If no improvement, identify new action steps 1/2008
- 16. Continuous Quality Improvement • Performance improvement will highlight processes and systems that need to be improved and follow-up with a plan of action to improve the outcomes. • The process is continuous. • Data continues to be collected and analyzed. • Services continue to identify performance concerns or goals: “performance indicators” 1/2008
- 17. Agency Mission Statement Helps to: • Establishing a Common Value and Philosophy of Care “The mission of House of New Hope is to transform the lives of vulnerable children in need of safe and permanent families, by providing treatment- oriented, culturally sensitive and cost effective community based services.” 1/2008
- 18. Performance Indicators Help to: • Establish a Common Focus • Establish a Common Definition of: o Good Business o Good Practice o Good Service Delivery 1/2008
- 19. Defining Service Performance Indicators • Outcomes: How do you know you are doing a good job with your clients? • Responsiveness • Satisfaction • Effectiveness o Improvement in functioning o Reduction in symptoms • Permanence o Reduced disruptions 1/2008
- 20. Defining Agency Performance Indicators • Licensing o Recruitment o Annual Number of Completed Home studies o Reduced withdrawals • Transportation o Safety o Met all appointments • Training o Applies knowledge gained o Rule violations o Satisfaction with training 1/2008
- 21. Defining Agency Indicators • Fiscal o Contract compliance o Billing hours budgeted met 1/2008
- 22. What measures do you use to determine that you are effective in your work? 1/2008