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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
Human 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
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23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …
Gary Smith, HSRI, 2003
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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.)
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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
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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
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CMS Quality InitiativeCMS Quality Initiative
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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.
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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
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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
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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
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Status of State RequestsStatus of State Requests
Active (8)
Active/Short Term (5)
Initial Exploration (4)
Referred (8)
Completed (0)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Participant Outcome and Participant Outcome and SatisfactionSatisfaction
Participant Participant satisfactionsatisfaction
Participant outcomesParticipant outcomes
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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
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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
Quality Management Functions
Design Discovery Remediation Improvement
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 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
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Review of Outcome-Review of Outcome-Focused Monitoring Focused Monitoring
Mechanisms Mechanisms
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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
Human Services Research InstituteHuman Services Research Institute
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
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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….
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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
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Conclusions and Conclusions and RecommendationsRecommendations
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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
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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
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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
Human Services Research InstituteHuman Services Research Institute
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
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