Human Services Research Institute Overview of Quality Assurance and Enhancement A Framework for Best...

Human Services Research InstituteHuman Services Research Institute

Overview of Quality Overview of Quality Assurance and Assurance and EnhancementEnhancement

A Framework for Best PracticeA Framework for Best Practice

Val BradleyVal BradleyHuman Services Research InstituteHuman Services Research Institute


Changing Quality LandscapeChanging Quality Landscape

Exposure of fault-lines in the Exposure of fault-lines in the system (e.g., CMS and the press)system (e.g., CMS and the press)

Emergence of self-determinationEmergence of self-determination Olmstead decision and proposed Olmstead decision and proposed

closuresclosures Struggles with MIS applicationsStruggles with MIS applications Direct support staff shortagesDirect support staff shortages Expansion of supports to Expansion of supports to

individuals on the waiting listindividuals on the waiting list


23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …

Gary Smith, HSRI, 2003


Decreasing/static funding – coming Decreasing/static funding – coming on top of already strained providerson top of already strained providers

Increasing federal expectationsIncreasing federal expectations Inefficient “business model” (e.g., Inefficient “business model” (e.g.,

clumsy rate structures, etc.)clumsy rate structures, etc.)


Signs of Change in Signs of Change in Performance ManagementPerformance Management

No longer just better than the institutionNo longer just better than the institution Rooted in outcomesRooted in outcomes Emphasis on enhancement and Emphasis on enhancement and

CQICQI Changing role of the stateChanging role of the state Changes in experiences of familiesChanges in experiences of families

and people with mental retardation and people with mental retardation Changes in accreditation Changes in accreditation

approaches approaches

Inclusion


More Signs of ChangeMore Signs of Change

Movement away from prescriptive Movement away from prescriptive

standards to individualized risk standards to individualized risk managementmanagement

Collaborative development of Collaborative development of standardsstandards

Inclusion of consumer and family Inclusion of consumer and family participation in oversightparticipation in oversight

Satisfaction

CQI

Consensus


CMS Quality InitiativeCMS Quality Initiative


Purpose of National Technical Purpose of National Technical AssistanceAssistance

To provide training and technical To provide training and technical assistance to CMS Central and assistance to CMS Central and Regional Offices and states in quality Regional Offices and states in quality assurance and improvement in HCBS assurance and improvement in HCBS waiver services for individuals with waiver services for individuals with developmental disabilities. developmental disabilities.


Major TasksMajor Tasks

To assess identify To assess identify trendstrends in quality issues in quality issues flowing from Regional Office HCBS waiver flowing from Regional Office HCBS waiver reviewsreviews

To provide To provide on-site and short-term technical on-site and short-term technical assistanceassistance to the states to address specific to the states to address specific quality and health and welfare concerns quality and health and welfare concerns

To provide To provide technical assistance to Regional technical assistance to Regional OfficesOffices regarding the content of HCBS regarding the content of HCBS waiver reviews, applications, renewals or waiver reviews, applications, renewals or amendmentsamendments


Major TasksMajor Tasks

To To respond to crisis situationsrespond to crisis situations at the at the request of CMS in order to provide Regional request of CMS in order to provide Regional Offices and/or states with rapid access to Offices and/or states with rapid access to potential remedies and resources.potential remedies and resources.

To provide To provide national consultationnational consultation and and technical assistance regarding quality technical assistance regarding quality assurance and improvement in the assurance and improvement in the implementation in HCBS waivers for people implementation in HCBS waivers for people with developmental disabilitieswith developmental disabilities


National Technical National Technical AssistanceAssistance

Resources available on HCBS.org: Resources available on HCBS.org: – 5 State Monitoring Review 5 State Monitoring Review – Root Cause AnalysisRoot Cause Analysis– Suggested CriteriaSuggested Criteria– Quality FrameworkQuality Framework– Future: Lessons learned, state examples, etc.Future: Lessons learned, state examples, etc.

Toolkits (e.g., state licensing and monitoring)Toolkits (e.g., state licensing and monitoring) Web-based conferencesWeb-based conferences ““Match making” between and among statesMatch making” between and among states Facilitated conference callsFacilitated conference calls


Status of State RequestsStatus of State Requests

Active (8)

Active/Short Term (5)

Initial Exploration (4)

Referred (8)

Completed (0)


Regional Office TrainingsRegional Office Trainings

November – Case management (Hill November – Case management (Hill and Mitchell)and Mitchell)

December – Behavior management December – Behavior management policies (Hitzing and Mullen)policies (Hitzing and Mullen)

March – Health and Medication – March – Health and Medication – (White-Scott(White-Scott

Videos will eventually be available on Videos will eventually be available on lineline


Other CMS InitiativesOther CMS Initiatives

Participant Experience SurveyParticipant Experience Survey Systems Change GrantsSystems Change Grants Development of Protocol guidelinesDevelopment of Protocol guidelines Identification of best practiceIdentification of best practice Systems Change grantsSystems Change grants Independence Plus templateIndependence Plus template Support for individuals moving out of Support for individuals moving out of

institutionsinstitutions TA for elderly and disabled waiver servicesTA for elderly and disabled waiver services


Emergence of Performance Emergence of Performance IndicatorsIndicators First appeared in behavioral First appeared in behavioral

and acute careand acute care Provide some “cues” for Provide some “cues” for

managing these complex managing these complex systemssystems

Highlight impact of cost Highlight impact of cost containmentcontainment

Illuminate what’s workingIlluminate what’s working Provide early warning signsProvide early warning signs


Characteristics of Characteristics of Performance IndicatorsPerformance Indicators

Reflect major Reflect major organizational or organizational or system goals.system goals.

Address issues Address issues that can be that can be influenced by the influenced by the organization or organization or systemsystem

Have face validityHave face validity

Point a directionPoint a direction Reflect rates or Reflect rates or

major events major events Related to Related to

associated associated standardsstandards


Participating NCI StatesParticipating NCI States

WA

IN

AZ

UT

NC

IL

IA

OK

VT

WV

KY

PA

MA

DE

RI

CT

MT

WY

NE

HI

Orange County

WA

IN

AZ

NC

IL

IA

OK

VT

WV

KY

PA

MA

DE

RI

CT

WY

NE

HI

Orange County

AL

SD

SC

ME


HCBS Quality FrameworkHCBS Quality Framework

rights and responsibiliti

es

Domains

Participant access

Provider capacity

and capabilities

Participantsafeguards

Participant outcomes and satisfaction

System performan

ce Participant-centered

service planning and

delivery

Participant rights and

responsibilities

QualityQuality


Participant AccessParticipant Access

Information and ReferralInformation and Referral Intake and EligibilityIntake and Eligibility

– User-friendly processesUser-friendly processes– Eligibility determinationEligibility determination– Referral to community servicesReferral to community services– Individualization of servicesIndividualization of services– Prompt initiationPrompt initiation


Participant-Centered Participant-Centered Service Planning and Service Planning and

DeliveryDelivery Participant-Centered PlanningParticipant-Centered Planning

– Adequate assessmentAdequate assessment– Free choice of providersFree choice of providers– Responsive service planResponsive service plan– Participant directionParticipant direction

Service DeliveryService Delivery– Ongoing service and support coordinationOngoing service and support coordination– Provision of needed servicesProvision of needed services– Ongoing monitoringOngoing monitoring– Responsiveness to changing needsResponsiveness to changing needs


Provider Capacity and Provider Capacity and CapabilitiesCapabilities

Availability of individual and Availability of individual and agency providersagency providers

Review of provider Review of provider qualificationsqualifications

Monitoring of providerMonitoring of providerperformanceperformance


Participant SafeguardsParticipant Safeguards

Prevention and investigation ofPrevention and investigation of abuse, neglect and exploitationabuse, neglect and exploitation

Tracking of major andTracking of major andunusual incidentsunusual incidents

Ensuring safety of housing and environmentEnsuring safety of housing and environment Regulation of behavior interventionsRegulation of behavior interventions Standards for medication managementStandards for medication management Provisions for personal safety and securityProvisions for personal safety and security Preparation for natural disasters and other Preparation for natural disasters and other

public emergenciespublic emergencies


Participant rights and Participant rights and responsibilitiesresponsibilities

Ensure that participants: Ensure that participants: Exercise civic and human rightsExercise civic and human rights Participate in decision making Participate in decision making

authorityauthority Have provisions for alternate Have provisions for alternate

decision makingdecision making Have access to due processHave access to due process

and grievance mechanismsand grievance mechanisms


Participant Outcome and Participant Outcome and SatisfactionSatisfaction

Participant Participant satisfactionsatisfaction

Participant outcomesParticipant outcomes


System PerformanceSystem Performance

Conduct system performance Conduct system performance appraisalsappraisals

Support quality improvementSupport quality improvement Ensure cultural competencyEnsure cultural competency Support participant & stakeholder Support participant & stakeholder

involvementinvolvement Maintain financial integrityMaintain financial integrity


Quality Management Functions

Design Discovery Remediation ImprovementQuality Framework

Participant Access

Provider Capacity and Capabilities

Participant Rights and Responsibilities

Participant-Centered Service Planning and Delivery

Participant Safeguards

Participant Outcomes and Satisfaction

System Performance

QUALITY MATRIX


Design Discovery Remediation Improvement


Design Discovery Remediation ImprovementQuality Framework

Participant Access






System Performance

Quality Framework

Participant Access






System Performance

QUALITY MATRIX


Review of Outcome-Review of Outcome-Focused Monitoring Focused Monitoring

Mechanisms Mechanisms


Immediate ChallengesImmediate Challenges

Quality assurance for individual Quality assurance for individual providersproviders

Sustainability of person-centered QASustainability of person-centered QA Effectiveness and efficiency of Effectiveness and efficiency of

current processescurrent processes Integration of information Integration of information Development of internal QA systemsDevelopment of internal QA systems


Integration of quality assurance Integration of quality assurance responsibilities across the systemresponsibilities across the system

Involvement of families and people Involvement of families and people with disabilitieswith disabilities

Improvement in up-front quality Improvement in up-front quality expectations upfront (e.g., expectations upfront (e.g., Pennsylvania).Pennsylvania).

Transparency of QA systems and Transparency of QA systems and development of a demand for informationdevelopment of a demand for information


Continuous Quality Continuous Quality ImprovementImprovement

Close the loopClose the loop

Information from quality assurance Information from quality assurance

drives decision making! drives decision making!

Therefore….Therefore….


Continuous Quality Continuous Quality ImprovementImprovement

QA ProcessesLicensing

Consumer surveyIncident management

Outcomes indicators

Plan of correctionProvider Qualification

Real time tracking of incidents and follow-up

Analysis of specific trends

BenchmarkingStrategic Planning

TrendsAnalysis


Conclusions and Conclusions and RecommendationsRecommendations


Important Next StepsImportant Next Steps Place individual outcomes at Place individual outcomes at

the center of the system the center of the system Enlist assistance of Enlist assistance of

consumers and familiesconsumers and families Identify key areas of Identify key areas of

performanceperformance Create a quality Create a quality

management entitymanagement entity Make results available and Make results available and

accessible accessible


Develop uniform reporting of critical Develop uniform reporting of critical health and safety events health and safety events

Develop staff credentialing and Develop staff credentialing and expand training optionsexpand training options

Reassess roles and responsibilities of Reassess roles and responsibilities of case managerscase managers

Refine performance contractingRefine performance contracting Develop quality management entityDevelop quality management entity


Expand understanding of participant Expand understanding of participant centered planningcentered planning

Develop a technical assistance Develop a technical assistance capacitycapacity

Implement risk management and Implement risk management and health assessmentshealth assessments

Build integrated data systemsBuild integrated data systems Develop hotlines and ombudspersonsDevelop hotlines and ombudspersons


Lessons for ProvidersLessons for Providers Develop internal quality improvement plansDevelop internal quality improvement plans Work with states to streamline QA/QE Work with states to streamline QA/QE

proceduresprocedures Continue to work to upgrade the status of Continue to work to upgrade the status of

direct support professionalsdirect support professionals Enlist people with disabilities and familiesEnlist people with disabilities and families Continue to train staff in person-centered Continue to train staff in person-centered

principlesprinciples Assume that quality assurance will become Assume that quality assurance will become

moremorecomprehensive and systematic comprehensive and systematic


Final WordsFinal Words

““Beware the Beware the Continuous Continuous Improvement of Improvement of Things Not Worth Things Not Worth ImprovingImproving””

W. Edwards DemingW. Edwards Deming

Human Services Research Institute Overview of Quality Assurance and Enhancement A Framework for Best...

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