ODP Community Services Quality Management Developing the Administrative Entity Quality Management...

ODP Community Services Quality Management

Developing the Administrative Entity Quality Management Quarterly Report

WebExFebruary, 2010

Ann Ligi, ODP Quality Management Lead – EastJodie Enterline, ODP Quality Management Lead – West

04/11/23

Learning Objectives

Explain AE QM Quarterly Report Expectations

Learn about Data Organization, Analysis and Reporting

Understand the Application of the PDCA Model

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AE Performance Objectives

AE QM Quarterly Report Includes all required elements Template is used Timely submission

Data Organization Tables and charts are used

PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis

Performance is monitored ongoing

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Reports Timeline

Reports Due 1st Q 2nd QAE submits QM Quarterly Report electronically to Regional Program Manager

April 30, 2010 July 31, 2010

Feedback to AE June 15, 2010 September 15, 2010

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Report Generation Timeline

Actions 1 2 3 4

Prior to QM Meeting

Retrieve data

Organize data (prepare tables, charts)

Generate DRAFT report

Provide to group prior to meeting

During QM Meeting

Discuss & interpret findings

Interpret & Analyze data; Identify patterns & trends; Apply C (check) of PDCA

Determine A (act) of PDCA; i.e.Maintain or Revise Action Plan

Determine PDCA Follow Up; Finalize draft report

After QM Meeting

Finalize report

Submit by due date 5

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AE QM Quarterly Report Template

Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives.

Administrative Entity: Date: Submitted by:

Focus Area and Desired Outcome:

Objective:

Performance Measures Findings and AnalysisIncorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist.

Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed.

Describe how key stakeholders are involved in the achievement of QM Plan objectives.

Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors.

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ODP QM Quarterly Report Evaluation Tool

Show evaluation tool and go through the questions.

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Complete the top section of the Quarterly Report using information from the AE Annual QM Plan


Administrative Entity: ABC Date: April, 2010 Submitted by: ABC QM Manager

Focus Area and Desired Outcome: Safeguards People are free from restraint

Objective: Reduce Incidents of Restraint by 20% by December 31, 2010



Number of restraints.Number of individuals restrained.Data Source: HCSIS – Data Warehouse



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Performance Measures were identified in the AE Annual QM Plan

2010 QM Plan Administrative Entity Name: ABC Focus Area: Safeguards

GOAL OUTCOME TARGET OBJECTIVEPERFORMANCE MEASURES/ DATA

SOURCE(S)/FREQUENCY/RESPONSIBLE PERSON

People are safe and secure in their homes and communities

People are free from restraint.

Reduce Incidents of Restraint by 20% by December 31, 2010

Baseline:Calendar Year 2009 = 100 restraints 10 individuals

Number of restraints.Number of individuals restrained.

Data Source: HCSIS, Data Warehouse

Frequency: Monthly

Person Responsible: ABC QM Manager

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Transfer the Performance Measures from the QM Plan to the Quarterly Report


Administrative Entity: ABC Date: April, 2010 Submitted by: ABC QM Manager

Focus Area and Desired Outcome: SafeguardsPeople are free from restraints

Objective: Reduce Incidents of Restraint by 20% by December 31, 2010



Number of restraints.Number of individuals restrained.Data Source: HCSIS – Data Warehouse



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AE QM Quarterly Report: Findings and Analysis




Objective:





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Completing the Findings and Analysis Section

Organize data – table Graphically display the data Analyze the data (CHECK)

After review of the data, what did we conclude?

If we conclude that we are not on track to achieve our objective, then why? (barriers)

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AE QM Quarterly Report: PDCA Follow-up




Objective:





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Completing PDCA Follow-up Section

If you identified barriers to achieving your objective, identify what you are doing or will do, to overcome the barriers. (ACT) These should be actions/activities on your

Action Plan If you’re on track to reach your objective,

identify what activities will be taken to sustain achievement and continue progress.

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AE QM Quarterly Report: Key Stakeholder Involvement




Objective:





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Completing Key Stakeholder Involvement Section

Who are Key Stakeholders? Waiver participants, their family

members or representatives, and Waiver providers including SCOs.

What kind of “involvement”? Involved in the identification of local

quality management priorities Involved in QI activities (meetings,

planning, implementation, reporting etc.)

See Section 5.15 of the 09-10 AE Operating Agreement

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AE QM Quarterly Report: Reporting to the MH/MR Board of Directors




Objective:





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Completing the Reporting to the MH/MR Board of Directors section

Document how frequently you report QI activities to the Board of Directors.

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QUESTIONS?

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PLAN

DOCHECK

ACT

C

Quality Resource Group of Hospital Corporation of America---1992 20

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PDCA Model

Plan how the improvement will be accomplished. Write an action plan that specifies actions taken to achieve the annual target

objective.

Do it. Implement the improvement plan. This includes education of staff and management about the process change.

Check the effect of the improvement Collect and analyze data Identify lessons learned. Determine the success or failure of the plan.

Act Hold the gains or Re-strategize steps in action plan and implement them Continue to monitor and evaluate progress.

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Determine baseline performance

Analyze baseline data

Develop an Action Plan for the improvement

Implement the plan

The PDCA Cycle - PLAN

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The PDCA Cycle - DO

Once you have a PLAN……. Conduct training

Implement (Just Do It!)

Use a Data Collection Tool

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The PDCA Cycle - CHECK

Review and analyze the performance data

Did the improvement work or not? If not successful, what were the

barriers?

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The PDCA Cycle - ACT

Based on success or lack of success in achieving your objective, ACT to maintain gains or modify your plan

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QUESTIONS?

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Data Organization, Analysis and Reporting

DATA

INFORMATION

KNOWLEDGEINFORMEDDECISIONS

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DATA - Organizing Data

Steps: 1. Retrieve data

2. Organize into a table

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DATA – Retrieve Data - Sources

HCSIS/Data Warehouse AE Data Collection Tools Surveys Comprised of individual cases, data

elements

See example

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ABC Communication Tracking Tool

Name: Date of ISP:

Information Reviewed

Check Appropriate Item

Complete, as Needed

Assessment/s Completed: Needed ? Indicate if Yes

(Date)

VerbalNon-verbal

Communication Needs, If Non-Verbal: Communication Supports/System NotesSystemTypeAvailableIn Working OrderRepair NeededUtilizedTraining NeededTraining Provided

________________

Follow up needed Yes/No04/11/23

Data Collection Tool ExampleABC Communication Tracking Tool -

ABC Communication Tracking Tool

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Aggregate the DataMultiple Cases/Month = Data

Draft 1-7-10

One case

done in month

All cases done in month

Data for that

month

July August September

# of individuals(# of ISPs)

# Non-Verbal

# w Comm. System 32

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DATA – Organize Data into Tables

Tables Columns

Categories Variables Time

Rows Individual cases Aggregate totals

See examples 33

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Example TableABC Primary Incidents FY 2008-2009

Incident Category July August Sep Oct Nov Dec Jan Feb Mar Apr May June Total

Abuse 21 22 19 23 21 17 23 17 25 30 27 12 257

Death 9 11 5 4 6 9 7 6 15 8 13 4 97

Emergency Closure 2 2 0 2 1 6 1 51 4 2 0 0 71

Emergency Room Visit 90 93 80 72 82 72 75 77 81 75 82 85 964

Fire 7 1 6 11 4 10 4 10 5 4 10 7 79

Hospitalization 42 30 37 35 24 44 41 38 31 41 41 27 431

Individual To Individual Abuse 34 40 37 27 32 36 39 34 46 37 48 43 453

Injury Requiring Treatment Beyond First Aid 9 1 6 9 4 9 6 7 8 9 7 4 79

Law Enforcement Activity 10 22 10 10 15 18 13 10 12 20 18 14 172

Medication Error 88 90 95 83 64 97 77 82 87 77 91 84 1,015

Missing Person 8 9 1 4 4 11 8 11 8 13 16 22 115

Misuse of Funds 7 2 12 28 5 4 4 5 2 5 1 3 78

Neglect 11 13 7 4 2 5 6 1 16 11 10 1 87

Psychiatric Hospitalization 10 8 14 11 12 14 15 10 12 19 13 16 154

Reportable Disease 0 1 1 0 0 0 1 2 0 0 1 2 8

Rights Violation 0 2 0 5 1 1 0 3 7 5 4 1 29

Suicide Attempt 0 0 0 0 0 0 0 0 0 0 0 0 0

Restraint 67 62 69 81 63 49 71 86 61 62 64 53 788

Total 415 409 399 409 340 402 391 450 420 418 446 378 4,877

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Example Table – 1st Q of Calendar Year

Measure Jan ‘10 Feb’10

Mar‘10

YTD Total1st Q

Restraints 13 11 14 38

Ind. restrained 4 5 4 5

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Organized Data - Tables

Measure Jan ‘10 Feb’10

Mar‘10

YTD Total1st Q

Restraints 13 11 14 38

Ind. restrained 4 5 4 5

Note: YTD Total is not 13 because we count each unique individual once.Finding: 5 individuals, 38 restraints

Some individuals experienced multiple restraints during the first quarter. 36

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INFORMATION – Transforming Data into Information

Create a chart/graph of the data Histogram/Bar Chart Line Chart/Run Chart

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INFORMATION - Bar Chart

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INFORMATION – Line Chart

# of Restraints and Persons Restrained

J an – March 2010

1311

14

45 5

0

2.5

5

7.5

10

12.5

15

J an Feb Mar

Fre

qu

en

cy

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INFORMATION – Bar Chart

ABC # of Restraints J anuary 2009 to March 2010

8

10

5

7

12

13

15

8

4

5

7

6

5

3

4

0

2

4

6

8

10

12

14

16

J an-09 Feb-09 Mar -09 Apr -09 May-09 J un-09 J ul -09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 J an-10 Feb-10 Mar -10

M onth

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INFORMATION - Line Chart

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KNOWLEDGE: Findings and Analysis

Based on the review of the Information, what can we conclude? Be aware of the potential to misinterpret data

Are we on track to reach our objective?

If we are not on track to reach our objective, do we have information that can help us to identify why we are not on track?

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Example Findings and Analysis

See sample report

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INFORMED DECISIONS – Recommendations and Follow -up

As a result of the analysis, identify recommendations and follow-up actions to be taken

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Example Recommendations and Follow-up

See separate sample report document

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WRAP UP

AE QM Quarterly Report Includes all required elements Template is used Timely submission

Data Organization Tables and charts are used

PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis

Performance is monitored ongoing

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QUESTIONS?

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Next Steps

WebEx will be posted Technical Assistance

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For further Technical Assistance Contact:

Ann Ligi ODP QM Lead – East [email protected] 570-443-4218 Jodie Enterline ODP QM Lead – West

[email protected]

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